The No Surprises Act
In order to protect consumers from “surprise” medical bills, Congress passed the Consolidated Appropriations Act, 2021 (CAA) which contained the No Surprises Act. The No Surprises Act prohibits you from being “balance billed” for Non-PPO Emergency Services, certain services by Non-PPO providers at a PPO hospital or ambulatory surgical center, and by Non-PPO provider air ambulance services.
Prior to the new law, Non-PPO providers were permitted to bill you for the difference between what the Plan agreed to pay and the full amount the out-of-network providers or facilities charged for a service. This was called “balance billing.” “Surprise billing” is an unexpected “balance bill.” This can happen when you have an emergency or when you schedule a visit at a PPO provider facility but are unexpectedly treated by a Non-PPO provider or use a Non-PPO provider air ambulance.
The No Surprises Act prohibits Non-PPO providers or facilities from balance-billing you in such situations unless you are informed of your option to receive the Non-PPO services and consent to such and accept responsibility for any balance-billing.
In addition, the No Surprises Act added other patient protections concerning continuity of care, provider directories, and access to external review for denials related to surprise billing protections. These new rules are effective beginning on or after July 1, 2022.
For more information, please refer to Welfare SPD/PD Amendment 3 and Your Rights and Protections Against Surprise Medical Bills.
Continuity of Care
The NECA-IBEW Welfare Trust Fund (“Fund”) provides Continuity of Care benefits to qualifying Eligible Persons when a provider or facility PPO-Network arrangement is terminated. Continuity of Care benefits must be approved by the Fund and can apply for up to 90 days after a “Continuity of Care Notice” is provided by the Fund, if the patient qualifies as a “continuing care patient.”
Please note that to qualify as a “continuing care patient,” you must meet one or more of the following criteria:
- treatment for a serious and complex condition
- undergoing institutional or inpatient care
- scheduled to undergo non-elective surgery (including related postoperative care)
- pregnancy or pregnancy treatment
- terminal illness
If the PPO-Network arrangement with your provider is terminated for any reason except fraud, and you qualify as a “continuing care patient,” then you have the right to receive transitional care from the provider. This is known as Continuity of Care. Under Continuity of Care, you may choose to continue your course of treatment under the same terms and conditions as if your provider was a PPO-Network provider for up to 90 days or until you no longer qualify as a “continuing care patient” (whichever is earlier).
Providers cannot balance bill you for qualifying Continuity of Care services. Balance billing is the difference between the provider’s billed charge and the Plan’s Allowable Charge for a service. If you apply and qualify for Continuity of Care benefits, then you will still be responsible for applicable Plan copays, deductibles, coinsurance, and out-of-pocket maximums.
If you believe you qualify and would like to request Continuity of Care benefits, then please contact the Fund Office as soon as possible to obtain a Request for Continuity of Care Benefits and Release of Information Form. This form can also be obtained from the Fund’s website. Phone and website details are listed below. Please note that all requests for Continuity of Care benefits are subject to Utilization Review to determine your qualifications as a “continuing care patient.”
You may also choose to find a PPO-Network provider to continue your treatment. You can find a list of PPO-Network providers through “Provider Finder” at www.bcbs.com/find-a-doctor
Complete details about Continuity of Care benefits can be found in Amendment No. 3 of the Fund’s 2020 Summary Plan Description and Plan Document (“SPD”). You can obtain a copy of Amendment No. 3, the Continuity of Care form, as well as the complete SPD, online at www.neca-ibew.org/Documents-and-Forms
If you have additional questions, or would like to request printed copies of Plan Documents, please contact the Fund Office at (800) 765-4239, option 6.
Quick Links to No Surprises Act/Continuity of Care Documents and Forms