DOL Releases RFI on Advanced Explanation of Benefits and Good Faith Estimates; Comments Due November 15

Published September 15, 2022

The Health and Human Services Department (HHS), the Internal Revenue Service (IRS), and the Employee Benefits Security Administration (EBSA) have issued a request for information (RFI) seeking comments to inform how the agencies make rules for advanced explanation of benefits (AEOB) and good faith estimate (GFE) requirements of the No Surprises Act, which was enacted as part of the Consolidated Appropriations Act, 2021 (CAA). 

Good Faith Estimate

The CAA requires providers and facilities, upon an individual’s scheduling of an item or service or upon an individual’s request, to inquire if the individual is enrolled in a group health plan or group or individual health insurance coverage. 
  • If the individual is enrolled in a plan or coverage and is seeking to have a claim for such item or service submitted to such plan or coverage, providers and facilities must provide to the plan, issuer, or carrier a GFE of the expected charges for furnishing the scheduled item or service (and any items or services reasonably expected to be provided in conjunction with those items or services, including those offered by another provider or facility), along with the predicted billing and diagnostic codes for these items or services. 
  • If the individual is not enrolled or is not seeking to have a claim for such item or service submitted to such plan or coverage (that is, an uninsured or self-pay individual), providers and facilities must provide the GFE directly to the individual.

Advanced Explanation of Benefits

The CAA requires group health plans and health insurance issuers offering group or individual health insurance coverage, upon receiving a GFE, to send a covered individual, through mail or electronic means, as requested by the covered individual, an AEOB in clear and understandable language.

This RFI seeks information and recommendations on: 
  • Transferring data from providers and facilities to plans, issuers, and carriers
  • Privacy concerns
  • With respect to post-stabilization services furnished by nonparticipating providers or facilities and nonemergency services performed by nonparticipating providers concerning patient visits to certain participating facilities, how to ensure that plans, issuers, and carriers have the requisite information to prepare an AEOB that takes into account an individual’s consent, or lack of consent, to waiving balance billing and cost-sharing protections.
  • How should the AEOB reflect the way in which the No Surprises Act’s or a State’s surprise billing and cost-sharing protections may affect an individual’s benefits related to the items or services specified in an AEOB and the individual’s financial responsibility for these items or services?
  • What unique barriers and challenges do underserved and marginalized communities face in understanding and accessing health care that the Departments and OPM should account for in implementing the AEOB and GFE requirements for covered individuals
  • Estimates of the time and cost burdens on providers and facilities, and separately on plans, issuers, and carriers, for building and maintaining a standards-based API for the real-time exchange of AEOB and GFE data. 
  • Extent to which providers, facilities, plans, issuers, and carriers are building and maintaining standards-based APIs for multiple purposes or already have standards-based APIs in place that they can leverage to implement AEOB and GFE requirements.

Comments are due November 15, 2022.