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

March, 2022 - Andrew Selesnick

March 24, 2022


By: Karen N. George and Andrew H. Selesnick


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.


For more information about the impact of this decision on your practice or facility, please contact Karen George at [email protected] or Andrew Selesnick at [email protected].



This communication is not intended to create or constitute, nor does it create or constitute, an attorney-client or any other legal relationship. No statement in this communication constitutes legal advice nor should any communication herein be construed, relied upon, or interpreted as legal advice. This communication is for general information purposes only regarding recent legal developments of interest, and is not a substitute for legal counsel on any subject matter. No reader should act or refrain from acting on the basis of any information included herein without seeking appropriate legal advice on the particular facts and circumstances affecting that reader. For more information, visit www.buchalter.com.


 



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