surprise! New Jersey health care providers face compliance with new federal out-of-network laws. Lowenstein Sandler LLP

In addition to funding federal and COVID-19 relief, the recently enacted Consolidated Appropriations Act of 2021 also includes legislation to protect patients from unexpected or “surprise” medical costs .

Effective January 1, 2022, the No Surprises Act protects patients from unexpectedly high medical bills provided by providers who are not within the patient’s health insurance network. In many cases, when an insured person receives “out-of-network” care, usually for emergency or unforeseen reasons, the patient’s health insurance does not cover some or all of the costs of these services and the remaining The patient will pay the cost. Specification.

Several states, including New Jersey, have enacted patchwork laws in recent years to curb the practice of passing on unpaid medical bills to patients. You are guaranteed price protection.

New Jersey Foreign Network Laws

In 2018, New Jersey enacted off-network consumer protection, transparency, cost containment, and accountability legislation. Prior to that, many of Garden State’s patients faced the potential for “awkward” medical bills if they unexpectedly received treatment at an out-of-network provider or out-of-network facility.

As one of the first states in the nation to enact comprehensive patient protection legislation, New Jersey included three key elements in the legislation: (1) Consumer Price Transparency and Network Disclosure Requirements. (2) establishing out-of-network payment dispute resolution processes between health insurance and health care providers; (3) Claims protection for patients who receive “inadvertent out-of-network services” or out-of-network services provided on an “emergency or emergency basis,” as those terms are defined in law. With just over a year of data reported, the law is starting to show promise. Out-of-network billing spending declined in both the personal and small employer health markets.

However, the state has generally been preempted from regulating self-funded health insurance plans, which are governed by the Employee Retirement Income Security Act of 1974, so that New Jersey is not eligible to receive medical services under self-funded insurance plans. Residents are not guaranteed the same protection as fully insured individuals or small patients. Employer plans regulated by state banking and insurance departments. Garden State providers must also similarly account for this dichotomy of regulatory frameworks when complying with New Jersey’s off-network laws.

Federal No Surprise Act

Similar to New Jersey law, the “No Surprises Act” renders patients harmless from unforeseen medical costs beyond liability for in-network cost-sharing under medical plans. Among other provisions, the law (1) prohibits differential billing; (2) require health plans and providers to enhance access to pricing information for healthcare services, network status, and advance notice of costs associated with healthcare; (3) establish a dispute resolution process for payment disputes between Plans and Providers;

1. Prohibition of Surprise Claims

Patients most often receive services from out-of-network providers in two scenarios: (1) receiving emergency care at an out-of-network hospital; or (2) receiving non-emergency care at an in-network facility, but with an out-of-network provider and without informed consent.

A patient who unexpectedly receives medical services from a provider outside the patient’s health insurance plan’s network will not be required to pay further, as if the provider were within the patient’s plan’s network. The law prohibits plans and providers from passing on additional “surprise” costs to patients.

2. Consumer transparency

The law also mandates greater transparency for both plans and health care providers so that patients can better understand their responsibility for paying costs before their scheduled checkup. Among these new transparency requirements, health insurers are required to provide members with a “detailed statement of benefits” before electing to disclose provider network status and a “good faith” estimate of member cost obligations. Must provide. Providers must likewise make efforts to obtain patient enrollment status and must disclose “good faith” estimates of expected charges.


When providers and plans cannot agree on payment for out-of-network services provided to eligible patients, the law establishes an “independent dispute resolution” process to resolve payment disputes through binding arbitration. Similar to winner-takes-all “baseball-style” arbitration, providers and plans submit payment offers to an independent arbitrator. An independent arbitrator will use a list of review criteria provided by Congress to decide between the two offers.


Garden State providers are valid until January 1, 2022, before the new law takes effect. In the meantime, providers will need to develop new policies and procedures to be prepared to comply with the law on its effective date, and conduct advanced training to keep their staff familiar with the legal requirements.

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