Texas Med. Assoc. v. HHS, 2022 WL 542879 (E.D. Tex. 2022); on attraction to fifth Cir., No. 22-40264, Doc. 00516304229 (Could 3, 2022)
On the request of the IRS, DOL, and HHS, the Fifth Circuit has put a maintain on the companies’ attraction of the trial court docket case vacating key parts of the interim ultimate rules implementing the unbiased dispute decision (IDR) provisions of the No Surprises Act, enacted as a part of the Consolidated Appropriations Act, 2021 (CAA). As background, this portion of the CAA is meant to protect people from shock medical payments for emergency providers, air ambulance providers furnished by nonparticipating suppliers (i.e., out-of-network suppliers or different suppliers that do not need contractual relationships with the plan), and non-emergency providers furnished by nonparticipating suppliers at in-network amenities in sure circumstances (see our Checkpoint article). The companies collectively issued two units of interim ultimate rules addressing, amongst different issues, participant cost-sharing for providers topic to the CAA, in most conditions utilizing the qualifying cost quantity (QPA), which relies on the plan’s median in-network charge (see our Checkpoint article). The rules additionally deal with procedural elements of plan funds of the out-of-network charge to nonparticipating suppliers and clarify the position of licensed IDR entities, the events’ submission of proposed cost quantities, and components licensed IDR entities could contemplate in choosing a celebration’s cost quantity (see our Checkpoint article).
Suppliers challenged the parts of the rules that successfully create the presumption that the QPA is the suitable out-of-network charge for figuring out the cost quantity, and a trial court docket invalidated provisions that prioritize the QPA over different components in figuring out the out-of-network charge (see our Checkpoint article). The companies issued a memorandum in response to the trial court docket’s ruling, saying that they had been “reviewing the court docket’s determination and contemplating subsequent steps.” The companies appealed the choice to the Fifth Circuit; nonetheless, at their request the court docket has now stayed the proceedings pending ongoing rulemaking.
EBIA Remark: This improvement provides to the lingering uncertainty in regards to the position of the QPA within the shock billing IDR course of. As we watch for future IDR rulemaking, understand that the companies have already revised their IDR course of guides in response to the trial court docket’s determination and introduced that the IDR Portal is open (see our Checkpoint article). Thus, however the uncertainty created by the court docket’s determination, the IDR course of is “stay.” Plans will must be ready for the brief and strict timelines and different elements of the IDR course of lately highlighted in FAQ steering (see our Checkpoint article). For extra info, see EBIA’s Well being Care Reform handbook at Part XII.B.3 (“Shock Medical Billing: Emergency and Non-Emergency Providers”). See additionally EBIA’s Group Well being Plan Mandates handbook at Part XIII.B (“Affected person Protections”) and EBIA’s Self-Insured Well being Plans handbook at Part XIII.C (“Federally Mandated Advantages”). You may additionally be curious about our webinar “Shock Billing Protections Beneath the No Surprises Act: What Group Well being Plans Ought to Know” (recorded on 5/11/2022).
Contributing Editors: EBIA Employees.