During a National Stakeholder Call on January 18, 2022, Ellen Montz—Deputy Administrator and Director of the Center for Consumer Information and Insurance Oversight (CCIIO) at the Centers for Medicare and Medicaid Services (CMS)—announced that CMS had begun publishing state-specific letters (the “Enforcement Letters”) detailing anticipated Federal and state responsibilities with respect to enforcement of the No Surprises Act (NSA) on the CCIIO website. Although CCIIO has yet to publish Enforcement Letters for a minority of states, the Enforcement Letters that have been published provide critical details regarding how the NSA intersects with existing state laws and CMS’s expectations regarding NSA enforcement in each state.
Among other guidance, the Enforcement Letters indicate:
- which NSA requirements will be enforced by specific states, and which requirements will be directly enforced by CMS;
- whether CMS expects specific states to enter into a collaborative enforcement agreement with CMS, pursuant to which the state agrees to perform compliance functions (e.g., policy form review, investigations, market conduct examinations, and consumer assistance) and refer specific cases to CMS for enforcement if the state is unable to obtain voluntary compliance; and
- whether the state has an all-payer model agreement or an existing specified state law or dispute resolution process that controls for determining out-of-network and/or uninsured (or self-pay) rates for services subject to the NSA.
The diversity of pre-NSA state laws addressing surprise and balance billing—which range from comprehensive to piecemeal—has presented significant challenges for stakeholders attempting to comply in good faith with the NSA in addition to state requirements, particularly in areas where state and Federal law do not align perfectly. Additionally, the NSA’s division of enforcement—with states as primary enforcers for most NSA provisions and CMS either enforcing or collaborating to enforce NSA provisions where states lack enforcement authority—added another layer of uncertainty regarding the approach different states might take to enforce the NSA.
While the Enforcement Letters provide some clarity for stakeholders trying to navigate and comply with the NSA and related state surprise billing laws through tailored state-specific Federal guidance, the intersection between the NSA and state law remains a complicated area. Many questions remain regarding how stakeholders should approach the more nuanced provisions of state laws that do not align perfectly with the NSA, and states continue to promulgate regulations and issue guidance regarding the relationship between state laws and the NSA (as an example, the New York Department of Financial Services recently published several detailed letters addressing the relationship between the NSA and New York law). As stakeholders patiently wait for CMS to issue the NSA enforcement final rule, they should expect the issuance of new guidance, rulemaking, and—on the state level—possibly legislation attempting to reconcile at least some of the NSA’s many provisions with state law. However, as the current landscape remains ripe with risk as the industry continues to grapple with overlapping—and sometimes incompatible—regulatory regimes, continued consciousness of state-level considerations remains paramount for stakeholders working to implement NSA compliance initiatives.
 As of February 11, 2022, CMS has not published Enforcement Letters for Alaska, Arizona, Illinois, Nevada, New York, Ohio, or Tennessee.
 The Administration issued a proposed rule addressing enforcement of the NSA on September 16, 2021. The comment period for the proposed rule that, in part, addressed enforcement of the NSA closed on October 18, 2021. See Requirements Related to Air Ambulance Services, Agent and Broker Disclosures, and Provider Enforcement, 86 Fed. Reg. 51730 (Sept. 16, 2021).