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No Surprises Act

Please note new Federal Law Effective January 1, 2022.

No Surprises Act

 

Effective January 1, 2022, the No  Surprises Act, which Congress passed as part of the Consolidated Appropriations Act of 2021, is designed to protect patients from  surprise bills for emergency services at out-of-network facilities or  for out-of-network providers at in-network facilities, holding them liable only for in-network cost-sharing amounts. The No Surprises Act also enables uninsured patients to receive a good faith estimate of the cost of care.

 

Billing Disclosures – Your Rights and Protections Against Surprise Medical Bills

 

When you get emergency care or get  treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or  balance billing.

 

What is “balance billing” (sometimes called “surprise billing”)? 

 

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a  copayment, coinsurance, and/or a deductible. You may have other costs or  have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers  and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference  between what your plan agreed to pay and the full amount charged for a  service. This is called “balance billing.”  This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit. 

“Surprise billing” is an unexpected  balance bill. This can happen when you can’t control who is involved in  your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an  out-of-network provider. 

 

You are protected from balance billing for: Emergency services 

 

If you have an emergency medical  condition and get emergency services from an out-of-network provider or  facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed  for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization  services.

This  law does not apply to nonemergency healthcare or medical services when a patient elects in advance and in writing to receive those services from  an out-of-network provider and when the out-of-network provider provides the patient with a written disclosure.   

  

Certain services at an in-network hospital or ambulatory surgical center 

 

When you get services from an  in-network hospital or ambulatory surgical center, certain providers  there may be out-of-network. In these cases, the most those providers  may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory,  neonatology, assistant surgeon, hospitalist, or intensivist services.  These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections. 

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network. 

 

When balance billing isn’t allowed, you also have the following protections: 

 

  • You  are only responsible for paying your share of the cost (like the  copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly. 

  • Your health plan generally must: 

  • Cover emergency services without requiring you to get approval for services in advance (prior authorization). 

  • Cover emergency services by out-of-network providers. 

  • Base what you owe the provider or facility (cost-sharing) on what it would  pay an in-network provider or facility and show that amount in your explanation of benefits. 

  • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit. 

 

 

Good Faith Estimate

 

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law, healthcare providers  need to give patients who don’t have insurance or who are not using  insurance an estimate of the bill for medical items and services.

 

  • You  have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment and hospital fees.

  • Make sure your healthcare provider gives you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your healthcare provider, and any other provider you  choose, for a Good Faith Estimate before you schedule an item or  service.

  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

  • Make sure to save a copy or picture of your Good Faith Estimate.

 

 

If you believe you’ve been wrongly billed, you may contact:

 

  • The U.S. Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (1-800-633-4227) or visit https://www.cms.gov/nosurprises for more information about your rights under federal law.