HHS Chart Summarizes Applicability of State and Other Surprise Billing IDR Processes

The U.S. Department of Health and Human Services (HHS) has provided various resources concerning the No Surprises Act, which was enacted as part of the Consolidated Appropriations Act, 2021 (CAA). These resources include a Chart for Determining the Applicability for the Federal Independent Dispute Resolution (IDR) Process.” This chart summarizes when a state or other IDR process applies instead of the federal IDR process. 

Surprise medical billing protections under the No Surprises Act are designed to protect consumers from unexpected bills for: 

  • Emergency services;
  • Air ambulance services by nonparticipating providers; and
  • Non-emergency services furnished by nonparticipating providers at in-network facilities. 

Interim final regulations issued by HHS address determining the amount payable for items or services under the surprise medical billing protections, including when parties must use the IDR process. 

When the Federal IDR Process Is Inapplicable 

Various situations exist in which the federal IDR process does not apply, including when:

  • Items and services are covered by Medicaid, Medicare, CHIP, or TRICARE; and
  • A method for determining the amount payable is provided under state law or an All-Payer Model Agreement under the Social Security Act.

The HHS chart helps determine whether the federal IDR, a state law, or an All-Payer Model Agreement applies in a particular case. For example, although the federal IDR process applies in most states and all U.S. territories, a state IDR process applies in four states: Alaska, Georgia, Maine, and Michigan. In another 18 states, a “bifurcated” process applies. So, parties in those states must review state law and consult state authorities to determine which IDR process applies.

To that end, HHS also has posted a list of links to the CAA Enforcement Letters sent to each state and U.S. territory. These letters explain whether the federal IDR process applies in each state or territory and under what circumstances. These letters also can be informative for parties trying to determine which IDR process applies in a particular state under certain conditions, especially in those 18 states with a bifurcated process. 

HBL has experience in all areas of benefits and employment law, offering a comprehensive solution to all your business benefits and HR/employment needs. We help ensure you are in compliance with the complex requirements of ERISA and the IRS code, as well as those laws that impact you and your employees. Together, we reduce your exposure to potential legal or financial penalties. Learn more by calling 470-571-1007.

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