No Surprises Act – Good Faith Estimate 2023 Updates

The No Surprises Act (NSA) imposed new requirements on health insurance plans and various types of providers (including community behavioral health providers) with the goal of reducing surprise medical bills and increasing price transparency for patients. Primarily impacting behavioral health providers, were the “good faith estimate” (GFE) requirements for patients who are uninsured or self-pay, effective 1/1/22. The NSA includes additional criteria for a good faith estimate related to insured patients that were initially proposed to become effective on 1/1/23. However, regulatory standards have not yet been developed for this requirement. CMS released an RFI on GFEs for insured individuals in mid-September. The RFI outlines the following requirement:

• Providers/facilities are required upon an individual's scheduling of an item or service, or upon an individual's request, to inquire if the individual is enrolled in a group health plan or group or individual health insurance coverage.
• If the individual is enrolled in a plan or coverage and is seeking to have a claim for such item or service submitted to such plan or coverage, providers and facilities must provide to the plan, issuer, or carrier, a good faith estimate (GFE) of the expected charges for furnishing the scheduled item or service (and any items or services reasonably expected to be provided in conjunction with those items or services, including those provided by another provider or facility), along with the expected billing and diagnostic codes for these items or services.
• If the individual is not enrolled or is not seeking to have a claim for such item or service submitted to such plan or coverage (that is, an uninsured or self-pay individual), providers and facilities must provide the GFE directly to the individual.

CMS has not specified when it expects to issue the proposed rule concerning these new GFE requirements but has indicated that stakeholders will have a reasonable time (typically 90 days) to comment on the proposal before the rule becomes final. The Ohio Council will share updates as they become available.