Health Benefits

Protections Against Surprise Medical Billing Take Effect January 1, 2022

Last year we shared information about how to avoid surprise medical bills, and this year we are delighted to provide an update. The No Surprises Act will take effect January 1, 2022, and CalPERS worked hard to support this federal action, including briefing members of Congress and their staff on our members’ experiences with surprise billing and providing educational sessions on California law.

The No Surprises Act: What You Need to Know

This new law will prohibit patients from getting bills for services when they unknowingly receive care from most out-of-network providers. The law will help protect CalPERS members and your family and friends who may have been at risk for large surprise bills.

Each year a small percentage of CalPERS members receive unwelcome surprise bills when they receive care from providers who are not in their health plan network. This can happen when:

  • You go to a health care facility, like a hospital or a lab in your plan’s network, and end up with a doctor who isn’t in network. You’re then charged more than you would have to pay for an in-network doctor.
  • You’re taken to a non-contracted emergency room and billed for the remaining balance for the services you got that weren’t covered.

Protections for HMO Members

Existing law already protects members in CalPERS health maintenance organization (HMO) plans from the practice of surprise billing, and Medicare and Medicare Advantage plans have their own limits and protections. The Knox-Keene Act, which governs HMOs in California, prohibits emergency department physicians from billing HMO patients for out-of-network emergency services and Assembly Bill 72 (2016) provides that if an HMO patient receives services at an in-network facility by an out-of-network physician, the patient is only required to pay the in-network price for those services.

Protections for PPO Members

The No Surprises Act will now offer similar protections for our preferred provider organization (PPO) plan members in the PERS Gold and PERS Platinum Basic plans for most, but not all, services. For example, the Act does not cover possible surprise bills for ground ambulance or some urgent care services, or bills for services the member consented to receive from out-of-network providers as outlined in the Act.

The intent of the new law is to take patients out of the billing mix by prohibiting providers from billing members directly. Instead, providers and insurers will be required to work together to determine appropriate payment amounts. The law will ensure patients have access to up-to-date information about which providers are in their health care network and the law also provides complaint, appeal, and dispute resolution processes.

Additionally, these federal protections should help protect patients who are exposed to out-of-network charges resulting from provider/insurer contract disputes, which have been on the rise in recent years.

Some regulatory changes may arise as the new processes are implemented, but the law and regulations released so far seem to provide long-needed protections. In the coming years, we will be watching how federal and state laws interact to protect our members and will monitor the circumstances that surprise bills continue to occur.

Learn More About the No Surprises Act

Attorney General Bonta Applauds No Surprises Act, California Department of Justice

New Protections for Consumers Take Effect in 2022, Kaiser Family Foundation

New Mandates Beginning January 1, 2022, Anthem Blue Cross