The federal No Surprises Act applies to individuals insured under individual and group health insurance plans, student health insurance plans, employer self-funded plans, non-federal governmental plans (state, county, and city plans) church plans, the Federal Employees Health Benefit plans, and to the uninsured.
The No Surprises Act DOES NOT apply to individuals covered under Short Term Limited Duration plans, critical illness policies, or other limited benefit plans or to Medicare, AHCCCS, Indian Health Services, Veterans Affairs Health Care, or TRICARE.
If you have an emergency medical condition and get emergency services from an
out-of-network provider, facility (such as a hospital or freestanding emergency room), or air ambulance company, the most the out-of-network provider, facility or air ambulance company may bill you is your plan’s in-network cost-sharing amount (such as deductibles, 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.
Any amounts you pay for emergency out-of-network services count toward your in-network deductible and out-of-pocket limit.
Certain services at an in-network hospital or ambulatory surgical center
When you get non-emergency services from an in-network hospital or ambulatory surgical center, certain providers at that facility may be out-of-network. In these cases, the most these providers may bill you is your share of the cost (like the deductibles, copayments, and coinsurance) that you would pay if the provider was in-network. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, surgeons and assistant surgeons, hospitalists, and intensivist services. These providers can’t balance bill you and cannot ask you to give up your protections not to be balance billed. Any amounts you pay for non-emergency out-of-network services from these providers count toward your deductible and out-of-pocket limit.
If you get other services from other kinds of out-of-network providers at these in-network facilities, the out-of-network providers can’t balance bill you, unless you give prior 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.
Under the NSA, your insurance company is required to make a payment to the provider, facility or air ambulance company within 30 days of receiving the provider’s claim. If the provider disagrees with the amount paid by the insurer, they can try to negotiate a higher payment amount directly with the insurer. If they can’t come to an agreement, an independent dispute resolution (IDR) process is available for providers and insurance companies to settle the payment dispute without putting you in the middle.
Uninsured and Self-Pay Patients
Patients without insurance or who do not want to submit a claim to their insurance company — often called “self-pay” — are also provided some NSA protections. Self-pay patients are entitled to receive a good faith estimate for the cost of services and procedures, including items or services that may be provided by other providers and facilities.
A good faith estimate for uninsured patients must also include information related to the patient/provider dispute resolution process that is used to determine the appropriate payment amount. When the difference between the good faith estimate provided and the bill an individual receives within 120 days of receipt of the item or service is at least $400, consumers will be eligible to use the Independent Dispute Resolution process. A dispute can be started online, by mail or fax. To start a dispute online, click the link for the Patient Provider Dispute Resolution Process (PPDR).
What to do if you believe you have been wrongly billed
You can review the website on the No Surprises Act. You can file a complaint with the federal government via the Consumer Web Form. Helpful tips on how to complete the complaint form can be found HERE. You can also call The No Surprises Help Desk at 1-800-985-3059 *8am - 8pm EST, 7 days a week.
Provider Requirements and Resources:
CMS has published information to inform and assist providers, facilities and air ambulance providers in understanding some of their new obligations under the NSA, including the prohibition against balance billing in certain circumstances, the requirements for disclosure of balance billing protections and transparency around health care costs, and the submission of updated provider directory information to health plans. For more information visit: https://www.cms.gov/nosurprises/Policies-and-Resources/Provider-requirements-and-resources
Providers can submit a complaint via the Provider Web Form.