When a health plan changes a provider’s network status, some patients may be able to continue treatment temporarily at in-network cost-sharing rates. The No Surprises Act, at 42 U.S.C. § 300gg-113, provides continuity-of-care protections, according to the Centers for Medicare & Medicaid Services (CMS).
Eligibility and limits
Some patients may request temporary continuation of care. The protection is not automatic: patients must apply, and health plans are required to notify members about the opportunity to continue care. When approved, the continuation period can last up to 90 days. During that period, the terminating provider must accept the plan’s payment and the patient’s in-network cost-sharing as payment in full, CMS guidance says.
The federal continuity-of-care protections apply to individual-market plans, employer-sponsored group coverage and Federal Employees Health Benefits plans. They do not extend to Medicare, Medicaid or TRICARE, which operate under separate rules, according to CMS.
Other rules affecting network changes
Separate federal provider-directory requirements call for health plans to verify directory information at least every 90 days. If a patient relies on inaccurate directory information, the plan must limit the patient’s costs to in-network rates, according to Lighthouse Lab Services.
Utah law requires managed care organizations to establish criteria for adding providers to network panels and file those criteria with the department; it addresses contract termination procedures separately, according to the Utah State Legislature. The Utah Insurance Department also operates an Office of Consumer Health Assistance, which offers residents an independent review process when insurance claims or appeals are denied.
Balance billing
Balance billing is when a provider charges a patient the difference between the provider’s charge and the amount paid by insurance.
What oversight records cover
The same Utah Insurance Department report says independent review primarily addresses denials involving medical necessity or experimental services, so it does not cover every denied claim. The report’s stated scope does not show how many network-change appeals were reviewed or how they were resolved. In a separate review of behavioral-health networks in Medicare Advantage and Medicaid managed care—not Rieske’s coverage—the HHS Office of Inspector General found that some plans listed inactive providers in their networks.
A prior authorization may be withdrawn for reasons such as missing documentation, medical-necessity questions, policy exclusions or clerical errors, KSL News reported. The station also reported that federal rules require health plans to check provider directories at least every 90 days.
The broader billing context
One in five insured adults had an unexpected out-of-network bill in the past two years, according to HHS ASPE.
A Utah patient’s case
KSL News reported that Payson resident Jennifer Rieske was billed more than $13,600 for surgery scheduled for April 16, though she expected to pay about $3,600, her deductible. Florida Blue authorized the procedure on March 31; the hospital left the insurer’s network on April 1. Florida Blue initially denied her appeal, saying the hospital was non-participating, according to KSL.
KSL later reported that a medical director reviewed Rieske’s request for continuation of treatment and that Florida Blue sent her a letter approving in-network billing.
