DMHC Reverses Course – No Surprises Act Does Not Apply to Out-of-Network Emergency Services Governed by the Knox-Keene Act

The DMHC issued its final guidance on the No Surprises Act, confirming that the Knox-Keene Act constitutes a “specified state law” under the Act. The out-of-network reimbursement requirements for emergency services and the dispute resolution process in the NSA will therefore not apply to DMHC claims. Instead, health plans must continue to comply with the Knox-Keene Act and California case law with respect to reimbursing out-of-network emergency providers and reimbursement disputes. This means that they must reimburse providers reasonably (as compared to the NSA’s median in-network rate) and that they can be sued in court if they do not. Emergency claims not covered by the Knox-Keene Act, unfortunately, will likely still be subject to the NSA and its dispute resolution process.

To read the full guidance issued by the DMHC to the health plans click here.


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