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- No Surprises Act Supersedes Adverse Indiana Out-Of-Network Law
A 2020 Indiana out-of-network balance billing law, that was strongly opposed by the Indiana Society of Pathologists and the CAP, was deemed by the Centers for Medicare and Medicaid Services (CMS) as not meeting the standards established by the federal “No Surprises Act.” Accordingly, the No Surprises Act, which took effect on January 1, 2022, will supersede the Indiana out-of-network law.
The Indiana out-of-network law had allowed health insurance plans to unilaterally determine payment for non-emergency physicians for out-of-network services at in-network facilities at whatever amount was deemed “allowable” by the plan. In addition, there was no provision for physician appeal or arbitration provided under state law. A physician coalition effort, supported by CAP, urged the Indiana state legislature to repeal or replace the law, but the legislature deferred to the CMS decision.
In a December 15 letter to Indiana state officials from the CMS, the agency stated that it “understands that Indiana does not have an applicable All-Payer Model Agreement or specified state law that would determine the out-of-network rate. Therefore, the federal independent dispute resolution process … will apply for purposes of determining the out-of-network rate with respect to items and services furnished to individuals in an insured group health plan, or group or individual health insurance coverage in Indiana by nonparticipating providers, nonparticipating emergency facilities, or nonparticipating providers of air ambulance services.” The CMS further stated that it will enforce the outcome of the federal independent dispute resolution process for cases in Indiana.