Key takeaways:
The No Surprises Act, which took effect January 1, 2022, is designed to keep people with private insurance from getting unexpected bills for out-of-network care at hospitals and outpatient surgery centers.
The new rules cover emergency care at any hospital and nonemergency care at in-network facilities.
Patients who still receive a surprise bill or feel pressure to pay can call the No Surprises Help Desk for assistance on next steps.
The situation varies, but the result is essentially the same: You receive care at a hospital or outpatient surgery center and then get a big, unexpected bill. The charges, in this case, come from a doctor or facility not in your health plan’s network. It’s this type of issue that the No Surprises Act aims to prevent.
In the past, people have received surprise medical bills in a few different ways:
In one, you get emergency care at a hospital that’s not covered by your insurance. The facility is out of network.
In another common scenario, you go to a hospital in your insurer’s network, but healthcare providers involved in your care are out of network.
In both cases, you were billed for the difference between what your health plan paid and what doctors or the facility charged. This is called balance billing.
Now, under the No Surprises Act (NSA), that’s not allowed. And if it does happen, you have recourse.
What is the No Surprises Act — and who does it cover?
In December 2020, then-President Trump signed the Consolidated Appropriations Act of 2021. The law contained new requirements to protect people with private insurance from surprise medical bills. These rules were collectively known as the No Surprises Act.
The No Surprises Act aims to help people avoid surprise bills for care at hospitals and surgery centers. But it doesn’t cover other types of medical facilities like urgent care centers. Also, while air-ambulance services can’t issue surprise bills, the same rules don’t apply to ambulances on the ground.
The NSA’s requirements apply to people with many different types of insurance but not all. And a plan needs to provide emergency care for the new rules to apply. Most plans do, but check if you’re not sure yours does.
If you’re insured through an employer, the health insurance marketplace, or have an individual health plan, you should be protected by the No Surprises Act, which took effect January 1, 2022. However, governmental insurance programs like Medicare and Medicaid aren’t covered by the NSA since these programs are already protected against surprise bills.
What are your rights under the No Surprises Act?
Patients covered by the No Surprises Act have a right to access emergency care from out-of-network providers without being charged extra. In short, you should not get a big bill that you didn’t expect for that care. Nor should you get a surprise bill for nonemergency care if you go to a facility covered by your insurance.
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But that hasn’t always been the case. “You could be going to a hospital that was in network but end up being treated by a doctor, who was out of network, in that hospital and get balance billed,” Braden Pan, chief executive officer and founder of the medical billing advocate Resolve in Hanover, New Hampshire, told GoodRx Health.
It’s a common scenario — or, it was. But under the law’s protections, that shouldn’t happen. Your other rights include:
No prior authorization required: You don’t have to make sure a hospital or doctor who practices at that facility is covered by your insurance before getting emergency care to avoid a surprise bill.
The No Surprises Act eliminates cost-sharing for most covered emergency and some nonemergency services, according to the Centers for Medicare & Medicaid Services. So you likely won’t pay a copay — a fixed amount for that care — or coinsurance, a percentage of the cost for that care. In cases where there is cost-sharing, you won’t pay more than the in-network amount.
You should get a notice about these billing protections at the hospital or surgery center, including information on who to contact (see below) if you have concerns.
The NSA doesn’t prevent all surprises related to out-of-pocket medical costs, however. Sometimes what seems like a surprise bill has more to do with the structure of your health plan than the bill itself, Caitlin Donovan, a healthcare policy expert and spokesperson for the National Patient Advocate Foundation in Washington, D.C., told GoodRx Health. For example, you may have a high-deductible plan but not realize how much of the deductible you still have to pay.
Review your explanation of benefits to better understand what your insurance covers after you receive care. Then compare that to your bill, Donovan says.
How to get help
If you received a surprise bill or have questions about the No Surprises Act, you can contact the No Surprises Help Desk for free at 1-800-985-3059. You can also file a complaint to the Centers for Medicare & Medicaid Services (click “submit a complaint”) if you feel a provider didn’t adhere to the NSA.
The help desk can be reached from 8 AM to 8 PM EST, 7 days a week. You may need to provide documentation, such as your medical bill and explanation of benefits, with your complaint. So, it’s a good idea to have those on hand if possible.
What does it mean if I sign a waiver?
In some cases, you may be asked to waive your protections against balance billing.
Certain providers, such as anesthesiologists and radiologists, are prohibited from balance billing in any scenario covered by the NSA. But other out-of-network providers are permitted to do this if they give patients notice first. This must happen before a patient receives care, and a patient isn’t required to agree or move forward with care.
In such cases, you must get a notice and consent form. This notifies a patient they could be balance billed if they get care from an out-of-network provider.
This can only happen if you are in stable condition and not receiving emergency care. It might be that you came to the hospital for an emergency, and your condition has stabilized. Or, you could be having an elective procedure, like a knee surgery.
Keep in mind: You could receive this paperwork at an in-network facility that’s covered by your insurance if you could get care there from an out-of-network doctor. “So you still have to be careful when you’re going to an in-network hospital and understand everything you’re signing,” Pan says.
You may choose not to sign the waiver and go elsewhere for care. Under the No Surprises Act, your plan must provide you with an updated list of in-network providers upon request (and you may also be able to access that through the plan’s site).
The important thing is to first read over what you’re waiving, experts say. Also, know what rights you still have. Namely, you have a right to know how much more your care will cost if you agree to receive an out-of-network bill.
What is a good faith estimate in healthcare?
A “good faith estimate” (GFE) is a written statement designed to help project your cost of care. In the case of a planned surgery, for example, a good faith estimate would include:
The surgeon’s fee
Anesthesiology fee
Facility charges
In some cases, you can request a GFE, and, in other cases, your healthcare provider may give you one. For example, you may receive a good faith estimate if you’re insured and you waive your protections against balance billing.
The NSA says uninsured and self-pay patients (those who pay out of their own pocket) also should get a good faith estimate if they want one. If you request a GFE because you’re uninsured or are paying cash, or you’re owed one because you waived protections against balance billing, you’re supposed to have this billing estimate in hand 3 hours before same-day care and at least 3 days before an elective procedure.
If your final charges are $400 or more over the good faith estimate, you can fight it through what’s called the patient-provider dispute resolution process. You’ll need to file a dispute within 120 days of the bill date. You can start by calling the No Surprises Help Desk or submitting a complaint online.
What should you do if you have an existing medical debt from a surprise bill?
You may be inclined to pay that unexpected medical bill as quickly as possible — that is, if you can afford to do so. But often there’s reason to wait.
“Any time you get a bill — but especially from a hospital — it’s always ‘delay before you pay,’” Donovan says. That strategy may seem counterintuitive or irresponsible, but medical bills frequently contain mistakes. Similarly, a debt collector can’t force you to pay a bill that exceeds what’s allowed under the NSA.
You can contact the Consumer Financial Protection Bureau (CFPB) if you have an issue with medical debt collection or credit reporting. To address unfair medical debt and related negative items on your credit report, call the CFPB at 1-855-411-2372 (CFPB) or file a complaint online.
The bottom line
The No Surprises Act protects people with private insurance from overbilling related to out-of-network care received at a hospital or surgery center. If you do get a surprise bill, you have options to fight it. A good place to start is the No Surprises Help Desk. In cases where medical debt or collections problems result from a surprise bill, the Consumer Financial Protection Bureau has resources that may help you protect your credit rating.
Why trust our experts?
References
Centers for Medicare & Medicaid Services. (n.d.). No Surprises: How do I read my medical bill?
Centers for Medicare & Medicaid Services. (n.d.). No Surprises: Healthcare notice & consent form: What to know before you sign.
Centers for Medicare & Medicaid Services. (n.d.). No Surprises: What’s a good faith estimate?
Centers for Medicare & Medicaid Services. (n.d.) The No Surprises Act’s good faith estimates and patient-provider dispute resolution requirements.
Centers for Medicare & Medicaid Services. (2022). Complaints about medical billing.
Centers for Medicare & Medicaid Services. (2022). Frequently asked questions for providers about the No Surprises rules.
Centers for Medicare & Medicaid Services. (2022). Medical bill disagreements if you’re uninsured.
Centers for Medicare & Medicaid Services. (2022). No surprises: Understand your rights against surprise medical bills.
Consumer Financial Protection Bureau. (n.d.) Submit a complaint.
Consumer Financial Protection Bureau. (2022). Know your rights and protections when it comes to medical bills and collections.
Healthcare.gov. (2022). Balance billing. U.S. Department of Health & Human Services.
