The No Surprises Act protects persons covered under group and individual health plans from receiving
surprise medical bills when they receive most emergency services, non-emergency services from outof-network providers at in-network facilities, and services from out-of-network air ambulance service
providers. It also sets up 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.
Starting in 2022, there are new protections that prevent surprise medical bills. If you have private health
insurance, these new protections ban the most common types of surprise bills. If you’re uninsured or you
decide not to use your health insurance for a service, under these protections, you can often get a good
faith estimate of the cost of your care up front, before your visit. If you disagree with your bill, you may be
able to dispute the charges. Here’s what you need to know about your new rights.
What are surprise medical bills?
- Before the No Surprises Act, if you had health insurance and received care from an out-of-network
provider or an out-of-network facility, even unknowingly, your health plan may not have covered the
entire out-of-network cost. This could have left you with higher costs than if you got care from an
in-network provider or facility. In addition to any out-of-network cost sharing you might have owed,
the out-of-network provider or facility could bill you for the difference between the billed charge
and the amount your health plan paid, unless banned by state law. This is called “balance billing.”
An unexpected balance bill from an out-of-network provider is also called a surprise medical bill.
People with Medicare and Medicaid already enjoy these protections and are not at risk for surprise
billing.
What are the new protections if I have health insurance?
If you get health coverage through your employer, a Health Insurance Marketplace®, 1 or an individual
health insurance plan you purchase directly from an insurance company, these new rules will: - Ban surprise bills for most emergency services, even if you get them out-of-network and without
approval beforehand (prior authorization). - Ban out-of-network cost-sharing (like out-of-network coinsurance or copayments) for most
emergency and some non-emergency services. You can’t be charged more than in-network cost sharing for these services. - Ban 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. - Require that health care providers and facilities give you an easy-to-understand notice explaining
the applicable billing protections, who to contact if you have concerns that a provider or facility has
violated the protections, and that patient consent is required to waive billing protections (i.e., you
must receive notice of and consent to being balance billed by an out-of-network provider).
1 Health Insurance Marketplace® is a registered service mark of the U.S. Department of Health & Human Services.
What if I don’t have health insurance or choose to pay for care on my own without using my health
insurance (also known as “self-paying”)?
If you don’t have insurance or you self-pay for care, in most cases, these new rules make sure you can get
a good faith estimate of how much your care will cost before you receive it.
What if I’m charged more than my good faith estimate?
For services provided in 2022, you can dispute a medical bill if your final charges are at least $400 higher
than your good faith estimate and you fIle your dispute claim within 120 days of the date on your bill.
What if I do not have insurance from an employer, a Marketplace, or an individual plan? Do these new
protections apply to me?
Some health insurance coverage programs already have protections against surprise medical bills. If
you have coverage through Medicare, Medicaid, or TRICARE, or receive care through the Indian Health
Services or Veterans Health Administration, you don’t need to worry because you’re already protected
against surprise medical bills from providers and facilities that participate in these programs.
What if my state has a surprise billing law?
The No Surprises Act supplements state surprise billing laws; it does not supplant them. The No Surprises
Act instead creates a “foor” for consumer protections against surprise bills from out-of-network
providers and related higher cost-sharing responsibility for patients. So as a general matter, as long as
a state’s surprise billing law provides at least the same level of consumer protections against surprise
bills and higher cost-sharing as does the No Surprises Act and its implementing regulations, the state
law generally will apply. For example, if your state operates its own patient-provider dispute resolution
process that determines appropriate payment rates for self-pay consumers and Health and Human
Services (HHS) has determined that the state’s process meets or exceeds the minimum requirements
under the federal patient-provider dispute resolution process, then HHS will defer to the state process
and would not accept such disputes into the Federal process.
As another example, if your state has an All-Payer Model Agreement or another state law that determines
payment amounts to out-of-network providers and facilities for a service, the All-Payer Model Agreement
or other state law will generally determine your cost-sharing amount and the out-of-network payment
rate
JEFF NEWMAN AND HIS FIRM ARE WHISTLEBLOWER LAWYERS HANDLING HEALTHCARE CLAIMS RELATING TO MEDICARE AND MEDICAID FRAUD UNDER THE FALSE CLAIMS ACT. HIS FIRM SITE IS WWW.JEFFNEWMANLAW.COM AND HE CAN BE REACHED AT JEFF@JEFFNEWMANLAW.COM OR AT 617-823-3217
