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What is a “surprise medical bill” and what should I know about the No Surprises Act?

A surprise medical bill is an unexpected bill from an out-of-network provider or at an out-of-network facility. Effective January 1, 2022, the No Surprises Act may protect you from surprise medical bills under certain circumstances.

Medical debts often occur after an accident or sudden illness. Consumers are rarely informed of the costs of medical treatment in advance and may have little or no ability to “shop around.” When you get a medical bill, you may not know if you actually received the billed treatment, if the correct amount was billed, if the amount is covered by insurance, and if the amount was already paid or partially paid.

What is a Surprise Medical Bill?

A surprise medical bill is an unexpected bill, often for services received from a health care provider or facility that you did not know was out-of-network until you were billed. Your health insurance may not cover the entire out-of-network cost which leaves you owing the difference between the billed cost and the amount your health insurance paid. This is known as “balance billing.” This bill could be for a service like anesthesiology or laboratory tests. You may not know that the provider or facility is out-of-network until you are billed.

How does the No Surprises Act protect me?

Effective January 1, 2022, the No Surprises Act (NSA) protects you from surprise billing if you have a group health plan or group or individual health insurance coverage, and bans:

  • Surprise bills for emergency services from an out-of-network provider or facility and without prior authorization

  • Out-of-network cost-sharing, like out-of-network coinsurance or copayments, for all emergency and some non-emergency services

  • Out-of-network charges and balance bills for supplemental care, like radiology or anesthesiology, by out-of-network providers that work at an in-network facility

The No Surprises Act also requires some health care facilities and providers to disclose Federal and State patient protections against balance billing and sets forth complaint processes with respect to violations of the protections against balance billing and out-of-network cost sharing.

If you don’t have health insurance or if you pay for care without using your health insurance, then you will get a “good faith” estimate of how much your care will cost BEFORE you get care. You can find more information on good faith estimates and your rights under the No Surprises Act here . If you’ve had your care and find that the billed amount is at least $400 above the good faith estimate, you may be able to dispute the charges through the patient-provider dispute resolution process .

You may already be protected against surprise medical billing if you have coverage through Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE.

If I have health insurance, can I waive my protections under the No Surprises Act?

According to the Centers for Medicare & Medicaid Services, out-of-network providers or emergency facilities may ask you to sign a notice and consent form before providing certain services after you’re no longer in need of emergency care. These are called “post-stabilization services.” You shouldn’t get this notice and consent form if you’re getting emergency services other than post-stabilization services. You may also be asked to sign a notice and consent form if you schedule certain non-emergency services with an out-of-network provider at an in-network hospital or ambulatory surgical center.

The notice and consent form informs you about your protections from unexpected medical bills, gives you the option to give up those protections and pay more for out-of-network care, and provides an estimate of what your out-of-network care might cost. You aren’t required to sign the form and shouldn’t sign the form if you didn’t have a choice of health care provider or facility before scheduling care. If you don’t sign, you may have to reschedule your care with a provider or facility in your health plan’s network.

View a notice and consent form (PDF)  from the Centers for Medicare & Medicaid Services.

What should I do if I receive a surprise bill and have a billing disagreement?

Your rights under the NSA depend on whether you have health insurance or if you are uninsured. In either case, you have rights.

If you are insured and your health plan denies all or part of a claim for service, you can appeal that decision. Your plan documents will contain information on the review process and how you request review of your plan’s decision.

Starting on January 1, 2022, you generally won’t be responsible for balance bills  or out-of-network  cost-sharing when getting emergency care, non-emergency care from out-of-network providers at certain in-network facilities, or air ambulance services from out-of-network providers. When this happens, instead of you paying for unexpected out-of-network costs, you’ll generally only need to pay your normal in-network costs (like coinsurance, copayments, and amounts paid towards deductibles). The health care provider and your health plan are responsible for negotiating the total payment amount from the plan to the provider through an independent dispute resolution process.

If you are uninsured or self-pay for insurance, starting on January 1, 2022, you should receive a good faith estimate of costs for your care from your provider when you either schedule that care or if you call and request the estimate. After you get the care, if you are billed for an amount more than $400 over the good faith estimate and you got the bill within the last 120 calendar days, you can use the new dispute resolution process to determine the final payment amount. This process uses a third-party arbitrator to review the good faith estimate, the final bill, and any other information submitted by your provider or facility.

Learn more about resolving billing disagreements. 

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