No Surprises Act
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 clients 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 clients to receive a good faith estimate of the cost of care.
Overview
Surprise billing occurs when clients receive care from out-of-network providers without their knowledge. This results in higher costs for medical services that would have been cheaper if rendered by providers inside their health plan’s network. It can happen when someone involved in the client’s care is not in-network. The rule is intended to cut down on surprise costs and also to ban out-of-network charges without advance notice (providing clients with plain-language consumer notice).
Your Rights and Protections Against Surprise Medical Bills
You are protected from balance billing when you get emergency care or are treated by an out- of-network provider at an in-network hospital or ambulatory surgical center. In these cases, you should not be charged more than your plan’s copayments, coinsurance, and/or deductible.
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, like a copayment, coinsurance, or deductible. You may incur additional costs or must pay the entire bill if you see a provider or visit a healthcare facility that is not in your health plan’s network.
“Out-of-network” means providers and facilities without a contract with your health plan to provide services. Out-of-network providers may bill you for the difference between what your plan pays 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 plan’s deductible or annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you cannot control who is involved in your care—like when you have an emergency or schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Depending on the procedure or service, surprise medical bills could cost thousands of dollars.
You are protected from balance billing for:
1. Emergency services - If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You cannot be balance-billed for these emergency services. This includes services you may
get after you are in stable condition unless you give written consent and give up your protections not to be balanced-billed for these post-stabilization services.
2. Certain services at an in-network hospital or ambulatory surgical center - When you receive services from an in-network hospital or ambulatory surgical center, certain providers at that location may be out-of-network. In these cases, the most they can 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 may not balance-bill you and may not ask you to give up your protections not to be balance-billed.
If you get other types of services at these in-network facilities, out-of-network providers may not balance-bill you unless you give written consent and give up your protections.
You are never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have these protections:
You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
Generally, your health plan must:
Cover emergency services without requiring you to get approval for services in advance (also known as “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 in-network deductible and out-of-pocket limit.
If you think you’ve been wrongly billed, you may contact 1-800-985-3059 for information and complaints. Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.