The IRS has issued Discover 2022-11 with steering for calculating the No Surprises Act’s qualifying fee quantity (QPA) for gadgets and providers furnished in 2022, when a well being plan doesn’t have adequate data to calculate the quantity beneath Income Process 2022-11. As background, the No Surprises Act, enacted as a part of the Consolidated Appropriations Act, 2021 (CAA), expanded affected person protections to defend people from shock payments for sure out-of-network emergency, air ambulance, and non-emergency providers (see our Checkpoint article). Individuals pay cost-sharing for gadgets and providers that fall inside the CAA’s scope based mostly on the “acknowledged quantity,” reasonably than the plan’s out-of-network cost-sharing. The acknowledged quantity typically would be the lesser of the QPA (which relies on the plan’s median in-network price for an merchandise or service) and the quantity billed by the supplier.
Laws issued in July 2021 present that for an merchandise or service furnished throughout 2022, the well being plan or insurer should calculate the QPA by rising the median contracted price for a similar or related merchandise or service beneath the plan or protection as of January 31, 2019, by the mixed share enhance within the client value index for all city shoppers (U.S. metropolis common) (CPI-U) over 2019, 2020, and 2021 (see our Checkpoint article). Income Process 2022-11 suggested that for 2022, the mixed share enhance to regulate the median contracted price is 1.0648523983 (see our Checkpoint article). Discover 2022-11 addresses gadgets or providers furnished in 2022 for which a plan or insurer doesn’t have adequate data to calculate the median of the contracted charges in 2019. On this state of affairs, the QPA have to be calculated by multiplying the median of the in-network allowed quantities for a similar or related merchandise or service supplied within the geographic area in 2021, drawn from any eligible database, by the share enhance of 1.0299772040. (The July 2021 laws present detailed pointers for figuring out an “eligible database.”) For a newly coated merchandise or service furnished in 2022, the QPA have to be calculated by multiplying the median of the in-network allowed quantities for a similar or related merchandise or service supplied within the geographic area in 2021, drawn from any eligible database, by the share enhance of 1.0299772040.
EBIA Remark: These chargeable for calculating the QPA on behalf of group well being plans and insurers might want to pay attention to this steering as they implement these advanced guidelines for 2022, protecting in thoughts that the 2022 QPAs will type the baseline for additional indexing in future years. For extra data, see EBIA’s Well being Care Reform handbook at Part XII.B.3 (“Shock Medical Billing: Emergency and Non-Emergency Providers”) and EBIA’s Group Well being Plan Mandates handbook at Part XIII.B.3 (“Affected person Protections: Shock Medical Billing (Emergency and Non-Emergency Providers)”). See additionally EBIA’s Self-Insured Well being Plans handbook at Part XIII.C (“Federally Mandated Advantages”).
Contributing Editors: EBIA Workers.
