Lawmakers are poised to soon pass a massive end-of-year legislative package including many healthcare industry priorities including a ban on surprise medical bills, money for vaccine distribution and COVID-19 testing and more funding and flexibility for provider grants, among other provisions.
Congressional leaders announced they have a deal on COVID-19 relief after months of gridlock and released the nearly 5,600-page bill on Monday. Both chambers are expected to vote on the full package as soon as Monday.
The agreement breaks paralysis that has gripped Washington for years on the issue of banning balance billing, or when consumers receive large bills for out-of-network care provided in emergency situations or at an in-network facility. A broad bipartisan coalition of lawmakers that had squabbled over details involving how insurers and providers should work out payment ultimately united on Dec. 11 for a final push to get a fix across the finish line.
The legislation attempts to protect patients from surprise medical bills in emergencies and non-emergency situations where patients can't choose an in-network provider. Patients would only be required to pay their in-network cost-sharing amount.
Insurers and providers could negotiate on a payment for the remaining bill for 30 days. If they can't agree, then they could use an arbitration process where the arbitrator is required to consider the median in-network payment rate for the service, the training of the provider, the parties' market share, prior contracting history, complexity of services, and other information submitted.
Hospitals and doctors scored a lobbying win by excluding Medicare and Medicaid payment rates from consideration by the arbitrator.
There is no cost threshold to enter arbitration. Providers could batch claims that are paid by the same insurers, and arbitration can only occur for the same service every 90 days.
The ban also applies to air ambulance providers. Air ambulance providers and insurers would be required to submit two years' worth of claims data to HHS.
Consumers would have additional protection from surprise medical bills if an out-of-network provider doesn't provide estimated charges and a notification of their status 72 hours before.
The new agreement eliminates a controversial benchmark payment that determined what insurers had to pay providers based on previously negotiated rates. Conservative groups had painted the benchmark payments as government rate setting.
The issue, which lawmakers have wrestled with since 2017, was a legacy item for Senate health committee Chair Lamar Alexander (R-Tenn.) and House Energy & Commerce ranking member Greg Walden (R-Ore.) who are retiring. Other lawmakers who endorsed the final deal include Senate health committee ranking member Patty Murray (D-Wash.), House Energy & Commerce Chair Frank Pallone (D-N.J.), House Ways & Means Chair Richard Neal (D-Mass.), Ways & Means ranking member Kevin Brady (R-Texas), House Education & Labor Chair Bobby Scott (D-Va.), Education & Labor ranking member Virginia Foxx (R-N.C.), and Sens. Bill Cassidy (R-La.), Maggie Hassan (D-N.H.) and Michael Bennet (D-Colo.).
While providers dodged bans on various types of clauses that make it difficult for plans to steer consumers to lower-cost or higher-quality providers, negotiators ultimately decided to ban gag clauses in contracts between providers and health plans. Gag clauses prevent enrollees, plan sponsors, or referring providers from seeing cost and quality data on providers.
The bill also requires states to report the supplemental Medicaid payments they make to providers. Disclosure of Medicaid supplemental payments has long been controversial.
Health plans are also required to report information about medical costs and prescription drug spending to the federal government. The bill also requires plans to report information to help the government ensure parity in coverage of benefits related to mental health and substance use disorders.
Several expiring Medicare and Medicaid programs are set to be extended. Funding for community health centers, the National Health Service Corps, and teaching health centers that operate Graduate Medical Education programs, and diabetes programs were extended for three fiscal years.
Lawmakers also decided to give hospitals a top ask by suspending the Medicare sequester that was supposed to end on Dec. 31 for three more months. Medicaid disproportionate-share hospital cuts are delayed through fiscal year 2023.
Specialty physicians were also concerned about Medicare pay cuts after CMS boosted pay for primary care providers in the Medicare Physician Fee Schedule, and lawmakers decided to boost payment rates by 3.75% across the board for the 2021 calendar year.
Lawmakers also gave accountable care organizations their top priority this cycle and froze for two years thresholds needed to secure a 5% bonus on annual Medicare payments.
Lawmakers decided to slash new Provider Relief Fund compared with a bipartisan framework for a relief bill. They settled on adding $3 billion to the fund instead of $35 billion, and require HHS to distribute at least 85% of the remaining grants via an application process that considers financial losses.
They also decided to overrule HHS and allow providers to use grant funds for lost revenue compared with budgeted revenue for 2020, instead of actual revenue from 2019. The tweak will allow providers to account for and keep a greater proportion of the grant funds.Health systems can also move distributions made for targeted purposes to other facilities within the system under the bill, which provides greater flexibility in using the funds.
The bill also includes $29 billion for vaccine distribution and more than $22 billion for testing and tracing.
Providers had advocated for several provisions that were left out of the relief bill, such as new funding for state and local governments to insulate providers from Medicaid pay cuts and a COVID-19 liability shield.