Commissioner Issues Directive on Self-Funded Plans Opting in to State Surprise Billing Law

On July 1, 2022, the Insurance and Safety Fire Commissioner (the Commissioner) issued Directive 22-EX-5 regarding self-funded healthcare plans electing to participate in the Surprise Billing Consumer Protection Act (the Act).

The Act (originally HB 888) was signed into law on July 16, 2020, and was designed to stop surprise billing to patients receiving out-of-network care for emergency services and non-emergency services at in-network facilities provided without patient consent. For covered items and services, an out-of-network provider may bill a patient only for the cost-sharing amount (e.g., deductible, coinsurance, copayment, etc.) that the patient is responsible for under the terms of his or her plan or policy. The Act specifies a formula to determine the amount the plan or insurer is required to pay the out-of-network provider and establishes an arbitration process for out-of-network providers who believe they should be entitled to additional funds. Subsequently, the Act was amended by SB 566 to clarify that a medical or traumatic condition, sickness, or injury includes a mental health condition or substance use disorder and that emergency medical services include post-stabilization services.

Generally, the Act applies to fully insured plans. However, on April 29, 2021, HB 234 was signed into law, allowing self-funded healthcare plans operating in Georgia to elect to participate in the Act. Directive 22-EX-5 provides the form and instructions for an electing self-funded healthcare plan to notify the Commissioner of its decision. Note that most non-electing self-funded plans would otherwise be subject to the federal No Surprises Act surprise billing prohibitions for plan years beginning on or after January 1, 2022. Electing plans may still be subject to the federal provisions for any items and services covered by the NSA that are not covered by the Act.

Self-funded employers should be aware of this bulletin and may want to consult with their counsel and service providers for further information and guidance.

Directive 22-EX-5 »
HB 234 »
HB 888 Final Rules and Regulations »
SB 566 »