New Protections Against Surprise Medical Bills
IMPORTANT NOTICE REGARDING NO SURPRISES ACT
This article is a Summary of Material Modifications intended to notify you of changes to your benefits relating to new protections against surprise medical bills from out-of-network providers under the No Surprises Act.
The No Surprises Act went into effect on January 1, 2022, and is intended to protect plan participants from the financial hardships caused by unexpected balance bills from out-of-network providers. A “balance bill” is a bill for the difference between an out-of-network provider’s billed charges and the amount the plan paid.
Under the No Surprises Act, the cost to you for certain services provided by out-of-network providers will be the same as if you have used a network provider.
The No Surprises Act is limited to emergency care, air ambulance services, some post-stabilization care after an emergency, and some types of non-emergency services received at in-network facilities.
Rather than bill patients for the difference between in-network rates and higher out-of-network fees, out-of-network providers are required to negotiate with insurers and to resolve disputes through a dispute resolution process established by the Department of Health and Human Services.
Specifically, the No Surprises Act:
Bans surprise bills for emergency services, even if received out-of-network and without prior authorization. This includes services you may get after you’re in stable condition, unless you give informed written consent to give up your protections not to be balance-billed for post-stabilization services or you are able to travel using non-medical transportation or nonemergency medical transportation to an available in-network provider or facility within a reasonable distance (and consent to waive balance billing protections);
Limits out-of-network cost-sharing requirements (like coinsurance or copayments) for all emergency and some non-emergency services to the requirements that would apply if the services were provided by an in-net- work provider or in-network emergency facility, and re- quires that cost-sharing amounts are calculated as if the total amount that would have been charged for the services were equal to the “recognized amount” (see below) for the services under the No Surprises Act; and any cost-sharing you pay counts towards your deductible and maximum out-of-pocket limits for the policy year;
Bans out-of-network charges and balance bills for non- emergency care received at an in-network facility or ambulatory surgical center when unknowingly treated by an out-of-network physician or laboratory; and
Bans out-of-network charges for air ambulance services.
Note:
You are never required to give up your protections from balance billing. You also are not required to get care out-of-network.
Non-emergency services from out-of-network providers at in-network facilities:
If you receive non-emergency services at an in-network facility from an out-of-network provider, and such services are otherwise covered by the Plan, you cannot be balance billed unless you have given informed written consent to give up your balance billing and cost sharing protections. However, you cannot give informed consent to give up balance billing and cost sharing protections, and will always be protected, for the following:
Items and services related to emergency medicine, anesthesiology, pathology, radiology, and neonatology;
Items and services provided by assistant surgeons, hospitalists, and intensivists;
Diagnostic services, including radiology and laboratory services;
Items and services provided by an out-of-network provider if there was no network provider who could furnish the item or service at the in-network facility; and
Items and services furnished as a result of unforeseen, urgent medical needs that arose at the time the item or service was furnished.
An “emergency medical condition” means a medical condition, including a mental health condition or sub- stance use disorder, manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possess an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
placement of the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
serious impairment to bodily functions, or
serious dysfunction of any bodily organ or part.
“Emergency services,” with respect to an emergency medical condition, include:
an appropriate medical screening examination to evaluate such emergency med- ical condition;
such further medical examination and treatment as are required to stabilize the patient; and
post-stabilization services as part of outpatient observation or an inpatient or outpatient stay related to the emergency medical condition until (i) the out-of-network provider or facility determines that the individual is able to travel using non-medical transportation or nonemergency medical transportation; (ii) the patient is supplied with notice that the provider or facility is out-of-network, estimated charges for additional treatment and any advance limitations that the Plan may put on the treatment, the names of any in-network providers at the facility who are able to treat the patient, and that the patient may elect to be referred to one of such in-network providers; and (iii) the patient gives informed consent to treatment by the out-of-network provider, acknowledging that the patient understands that continued treatment by the out-of-network provider may result in greater cost to the patient.
The “recognized amount” for services covered by the No Surprises Act means one of the following:
an amount determined by an applicable All-Payer Model Agreement under section 1115A of the Social Security Act;
if there is no applicable All-Payer Model Agreement, and amount determined by a specified state law; or
if there is no applicable All-Payer Model Agreement or state law, the lesser of the amount billed by the provider or facility or the Qualifying Payment Amount (QPA). The QPA means generally the median contracted rates of the plan or issuer for the item or service in the geographic region, calculated in accordance with 29 CFR 716-6(c).
When balance billing is prohibited, you are only responsible for paying your share of the cost (e.g., copayments, coinsurance, and deductible requirements that you would pay if the provider or facility was in-network). The Plan will pay out-of-network providers and facilities directly.
Eligibility thresholds will change in 2024
Eligibility thresholds will increase for Levels A and B for the qualifying period, October 3, 2022 through October 2, 2023, which determine coverage for the 2024 calendar year. Please note that the eligibility threshold ($700) for Level C will not change.
Eligibility for health coverage through the Fund is determined by your employer(s) contributions to the Fund for the Qualifying Period of October 3, 2022 through October 2, 2023. This Qualifying Period will determine your eligibility for health care in the following calendar year’s Coverage Period (January 1st through December 31, 2024). The employer contributions to qualify for Levels A, B, and C are as shown below:
The Trustees are aware that the COVID-19 pandemic deeply affected musicians. During the last two and a half years, the Trust paid for musicians’ premiums out of Fund reserves in order to ensure that musicians continued to receive health coverage, despite the gross reduction in employer contributions. The Trustees, after much deliberation decided to make the changes outlined in this edition of Benefits Report.
This notice is a Summary of Material Modifications to the Trust’s Summary Plan Description (SPD), and constitutes an addendum to the SPD. We are furnishing it to you in accordance with U.S. Department of Labor regulations §§2520.104b-3 and 2590.715-2715(b). If there is any inconsistency between this notice and the official Plan documents and contracts, the official Plan documents and contracts will control to the extent not amended by this notice. If you have any questions regarding this notice, please contact the Administrative Office during normal business hours at (818) 243-0222 or toll-free at (800) 753-0222, or email your questions to: enrollment@pacfed.com.