Orlando Harmon
The No Surprises Act, which came into effect on January 1, 2022, protects consumers from surprise or unexpected medical bills from out-of-network providers or facilities. Surprise bills can arise in emergencies when patients have little to no say in where they receive care, or in non-emergencies when patients at in-network hospitals receive care from out-of-network providers whom they did not choose. The Act also establishes an independent dispute resolution process for payment disputes between plans and providers, and provides new dispute resolution opportunities for uninsured and self-pay individuals when they receive a medical bill that is substantially greater than the good faith estimate they get from the provider.
| Characteristics | Values |
|---|---|
| Definition | A surprise medical bill is an unexpected bill from an out-of-network provider or at an out-of-network facility. |
| Protection | The No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services. |
| Exceptions | Ground ambulance services aren’t covered by billing protections in the No Surprises Act. |
| Balance billing | If your health insurance covers emergency care, you can't be charged more for emergency medical services than the in-network “cost-sharing” rate. |
| Post-stabilization services | Out-of-network providers may ask you to sign a notice and consent form to waive your protections before providing certain services after you’re no longer in need of emergency care. |
| Dispute resolution | The No Surprises Act establishes an independent dispute resolution process for payment disputes between plans and providers. |
| Good faith estimate | If you don’t have insurance or you self-pay for care, in most cases, you can get a good faith estimate of how much your care will cost before you receive it. |
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What You'll Learn
The No Surprises Act
The Act establishes an independent dispute resolution process for payment disputes between plans and providers. It also provides new dispute resolution opportunities for uninsured and self-pay individuals when they receive a medical bill that is substantially greater than the good-faith estimate they get from the provider.
The Act also bans out-of-network charges and balance bills for certain additional services, like anesthesiology or radiology, furnished by out-of-network providers as part of a patient's visit to an in-network facility. It requires that healthcare providers and facilities give patients an easy-to-understand notice explaining the applicable billing protections and who to contact if they believe their rights have been violated.
If you have a question about the No Surprises Act or believe the law isn't being followed, you can take action by contacting the Centers for Medicare & Medicaid Services No Surprises Help Desk at 1-800-985-3059 from 8 am to 8 pm EST, 7 days a week, or submitting a complaint online.
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Surprise medical bills
The No Surprises Act, which came into effect on January 1, 2022, protects people covered under group and individual health plans from receiving surprise medical bills in most cases. It bans surprise bills for most emergency services, even if they are received out-of-network and without prior authorization. It also prohibits out-of-network cost-sharing for most emergency services and some non-emergency services, meaning patients can't be charged more than in-network cost-sharing rates. Additionally, it bans out-of-network charges and balance bills for certain additional services, such as anesthesiology or radiology, provided by out-of-network providers during a patient's visit to an in-network facility.
The Act also establishes an independent dispute resolution process for payment disputes between plans and providers and provides new dispute resolution opportunities for the uninsured and self-pay individuals when they receive a bill that is significantly higher than the good faith estimate provided by the provider. If you have private health insurance, these new protections ban the most common types of surprise bills. If you are uninsured or choose not to use your insurance, you can often get a good faith estimate of the cost of your care upfront.
Surprise bills typically occur when an out-of-network provider treats a patient at an in-network hospital or ambulatory surgical center, or when an in-network doctor refers a patient to an out-of-network provider. In these cases, patients are only responsible for paying their in-network cost-sharing (copayment, coinsurance, or deductible). It is important to note that it is not considered a surprise bill if the patient chooses to receive services from an out-of-network provider when an in-network option is available.
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Cost-sharing
A copayment, or copay, is a fixed fee you pay for a covered service, such as a doctor's visit or a prescription medication. The amount of the copay depends on the service received and the terms of your insurance plan.
A deductible is an amount you must pay out-of-pocket each year before your health insurance plan starts paying for most of your medical bills and other covered services. For example, if your deductible is $500, you will have to pay the full amount for your medical expenses until you reach that $500 threshold. Some plans have multiple deductibles, such as separate deductibles for in-network and out-of-network care. It is important to note that certain services, like preventive care, may be exempt from deductibles.
Coinsurance refers to the percentage of the medical cost that you are responsible for after you have met your deductible. For example, if your surgery costs $10,000 and you have a 20% coinsurance, you will pay $2,000, and your insurance will cover the remaining $8,000. Health insurance plans usually have out-of-pocket maximums, which means that once you reach a certain amount in out-of-pocket expenses, your insurance will cover 100% of the costs for covered services.
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Balance billing
While balance billing can occur in emergency situations, federal law and the No Surprises Act provide protections against surprise bills for emergency services in hospitals, hospital outpatient departments, and independent freestanding emergency departments. These protections also extend to certain services, such as radiology, laboratory, and anaesthesiology, even if the patient receives notice that the provider is out-of-network.
It's important to note that balance billing is prohibited for in-network providers or providers that accept Medicare assignment. Violating these terms can result in penalties, fines, or even criminal charges. Additionally, patients have the right to dispute surprise bills through the New York State independent dispute resolution process or by submitting a complaint regarding the No Surprises Act.
To avoid unexpected balance billing, patients should understand their insurance plan's coverage, including emergency care and out-of-network benefits. They should also be aware of their rights and protections under the No Surprises Act, which took effect in January 2022, to prevent unexpected financial burdens.
While balance billing can be a stressful experience, understanding your insurance coverage and knowing your rights can help you navigate these situations effectively.
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Independent dispute resolution
Surprise billing, or balance billing, refers to unexpected out-of-network charges for emergency medical services. The No Surprises Act, which came into effect in 2022, prohibits surprise billing for some services and established a new process called independent dispute resolution (IDR) to handle billing disputes.
The IDR process is a voluntary forum for healthcare providers and health insurance issuers to resolve disputes about how much should be paid for out-of-network care. It is managed by the Department of Health and Human Services, the Department of Labor, and the Department of the Treasury. The process is as follows: when a provider or facility receives a payment denial or an initial payment from a health plan for out-of-network services, there must be an open negotiation period lasting 30 business days (or about 42 calendar days). If the health plan and provider or facility cannot agree on a payment amount during this period, either party can initiate the IDR process within 4 business days of the negotiation period ending. The certified IDR entity then selects from the disputing parties' payment offers, and both parties must abide by the decision and make payment within 30 calendar days.
The No Surprises Act also established protections for patients receiving surprise bills. For example, if you go to the emergency room, you are generally protected from unexpected out-of-network charges for emergency medical services. If your health insurance covers emergency care, you cannot be charged more for emergency services than the in-network cost-sharing rate. Additionally, ground ambulance services are not covered by billing protections in the No Surprises Act unless a state law specifies different rules.
If patients believe they have received a surprise bill, they can submit a complaint to the No Surprises Help Desk.
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Frequently asked questions
A surprise medical bill is an unexpected bill from an out-of-network provider or facility.
The No Surprises Act is a law that protects consumers from surprise medical bills. It was enacted in December 2020 and came into effect on January 1, 2022.
The No Surprises Act contains key protections to hold consumers harmless from the cost of unanticipated out-of-network medical bills. It also establishes an independent dispute resolution process for payment disputes between plans and providers.
A surprise bill can occur when an out-of-network provider treats you at an in-network hospital or ambulatory surgical center, or when you are referred by an in-network doctor to an out-of-network provider.
If you receive a surprise bill, you can submit a complaint to the No Surprises Help Desk or call them at 1-800-985-3059. You can also talk to your insurer, provider, or a patient advocate.
