Comment on FR Doc # 2010-15277

Re: Comment on 45 CFR 147.138(b) Suggested change: Add a section to 45 CFR 147.138(b) that requires a non-grandfathered plan to notify the beneficiary (via a reason code for each emergency service line on the explanation of benefits it provides the beneficiary) and medical professional and/or hospitals (via a reason code for each emergency service line on the reimbursement advise it provides a ER professionals and/or hospitals) that- (a) the plan is a non-grandfathered plan and has determined its payment obligation for this covered emergency services line-item pursuant to the provisions 45 CFR 147.138(b)(3); or (c) ) the plan is a non-grandfathered plan and the plan has determined that the emergency services billed under this line-charge are not covered pursuant to the definitions in 45 CFR 147.138(b)(4). Discussion: There is nothing in existing regulations, as far as I can determine, that requires a plan to inform a beneficiary or a provider (physician and/or facility) if the out-of-network payment rules of 45 CFR 147.138(b(3)) apply to each line-item that has been billed for out-of-network emergency services. Absent this information neither beneficiaries nor providers will be able to easily flag questionable line-item payments by non-grandfathered plans for emergency services. This undercuts the consumer protections in the proposed regulations (29 CFR Part 2590) which provide beneficiaries and providers with access to a streamlined dispute resolution process should they wish to dispute: (i) a non-grandfathered plan’s determination that the services rendered do not meet certain medical necessity criteria (e.g.: the definition of covered emergency services in 45 CFR 147.138(b)(4); and/or (ii) (ii) that the amount being paid by non-grandfathered plan does not comply with the plan’s out-of-network payment obligations pursuant to federal regulations (45 CFR 147.138(b)(3) ).