HHS Requests Stakeholder Feedback on Good Faith Estimate Requirements

HHS, along with three other federal agencies, has issued a request for information (RFI) to gather stakeholder feedback on the advanced explanation of benefits (AEOB) and good faith estimate (GFE) requirements of the No Surprises Act.

When an individual enrolled in group or individual health insurance coverage schedules an item or service, the provider or facility must provide the plan, issuer, or carrier with a good faith estimate of the expected charges for the service. If the person seeking care is uninsured or a self-pay individual, the provider must submit the GFE directly to the individual.

If uninsured or self-pay individuals schedule a service at least three business days ahead, facilities must provide the GFE within one business day after the date of scheduling. If a service is scheduled at least ten business days in advance or an individual requests a GFE, the GFE must be provided within three business days of the request.

In the case of insured individuals, health insurance plans must provide members with an advanced explanation of benefits upon receiving a GFE. The AEOB must include the network status of the provider or facility, the contracted rate for the service, the GFE from the provider, a GFE of the amount the plan is responsible for paying, and the cost-sharing amount.

The No Surprises Act went into effect on January 1, 2022, but HHS has deferred enforcement of the GFE and AEOB requirements in response to stakeholder requests.

The RFI issued by HHS, the Department of the Treasury, the Department of Labor (collectively, the Departments), and the Office of Personnel Management (OPM) seeks feedback from healthcare providers and facilities, payers, third-party vendors, and individuals eligible to receive an AEOB.

The first section of the RFI focuses on transferring data from providers and facilities to plans, issuers, and carriers.

The Departments and OPM asked stakeholders what issues they should consider as they weigh policies to encourage the use of a Fast Healthcare Interoperability Resources (FHIR)-based Application Programming Interface (API) for the real-time exchange of AEOB and GFE data.

Transactions related to AEOB and GFE data do not require HIPAA administrative provisions but must follow HIPAA privacy and security rules. OPM and the Departments requested feedback on the potential privacy concerns that the transfer of AEOB and GFE data raises and how the agencies should address these concerns.

In addition, the agencies asked how they could update the ONC Health IT Certification Program to support data exchange between providers and health plans.

The RFI also included questions about the barriers that small, rural, and other providers face when complying with industry-wide standards-based API technology requirements for exchanging AEOB and GFE data and how the agencies can address these barriers.

The second section of the RFI focused on other policy considerations. The agencies included several questions about how to ensure that health plans have the requisite information to prepare an AEOB that considers an individual’s consent or lack thereof to waive balance billing and cost-sharing protections.

The RFI also seeks to gather feedback on how the AEOB should reflect how surprise billing and cost-sharing protections impact an individual’s financial responsibility for a service specified in an AEOB.

The agencies wanted to know what they should consider when determining what items or services have low utilization or significant variation in costs to modify AEOB timing requirements and requested examples of these services.

The agencies also inquired whether providers and health plans would face additional burden if they were required to verify patients’ coverage status and coverage for items and services included in an AEOB of GFE.

The last section of the RFI seeks to understand the potential economic impacts of implementing AEOB and GFE requirements for covered individuals.

The Departments and OPM requested estimates of the time and cost burdens on providers and health plans for building and maintaining a standards-based API for real-time AEOB and GFE data exchange. The agencies also asked for any factors that might affect the number of providers and facilities that would incur the burden and cost of providing a GFE to health plans.

Healthcare stakeholders can submit feedback electronically or via regular mail until November 15.