The landscape of healthcare legislation is everchanging. Each year, self-funded health plans have specific reporting requirements, certain rules to follow, and distinct guidelines for what should and should not be covered in their plan. Without a true compliance partner, employers can face stiff penalties for not complying with state and federal laws.
At Concierge, we stay on top of all state and federal legislation to ensure our clients and members are well-versed on new rules, additional regulations, and upcoming deadlines.
Expressed in this protection rights are defined as balance-billing that plan members receive for services rendered from an out-of-network provider by no choice of the plan member. This may include emergency services provided at an Urgent Care Center, non-emergency services rendered at an in-network Hospital or Ambulatory Surgical Center who requests the services of an out-of-network provider, and in-network PPO contract changes.
FREESTANDING URGENT CARE CENTER
Visits for emergency care services that are out-of-network with your benefit plan’s PPO network, will be considered at the in-network benefit rate for the physician office visit charge.
NON-EMERGENCY SERVICES PROVIDED BY AN IN-NETWORK HOSPITAL OR AMBULATORY SURGICAL CENTER
Who by no choice of the plan member acquires covered coordinating services from an out-of-network provider, the covered services will be considered at the in-network rate (such as but not limited to, preventive care services required by the ACA, anesthesia for a covered preventive care service, laboratory services, diagnostic testing and readings that are listed as covered expenses of the Plan. See your benefit Plan for a list of covered benefits).
CONTINUITY OF CARE
If a plan member is receiving continued care for on-going medical conditions (such as, but not limited to terminal illness, postoperative care, cancer, and pregnancies) from an in-network provider or facility and the provider’s network status changes to out-of-network, the plan member can continue to receive care from the provider at the in-network rate for 90 days. The provision does not apply if the provider or facility contract is terminated with good cause, such as fraud or failing to meet standards. The Plan will notify plan members of the change in network status from in-network to out-of-network and the right to continued care for on-going medical conditions.
If you have questions about the impact a specific piece of legislation has on your coverage, organization, or employees, please contact our team.