Sometime surprises are good, sometimes they are not. Surprised at your birthday party…. good (depending on your age). Surprised at the car repair shop…. usually bad. Another one of those bad experiences is when a medical bill arrives, and it is much higher than you thought. Especially if it is a substantial bill, surprises like that can cause you to worry and fret over how you are going to make ends meet. However, on January 1st, 2022, the new No Surprises Act went into effect and just recently, as of June 14, 2023, the Centers for Medicare & Medicaid Services (CMS) made available new consumer-friendly web pages for people with easy-to-read information regarding the consumer protections in this legislation.
What is the No Surprises Act?
The No Surprises Act is exactly what the name says it is. It protects people covered under group and individual health plans from receiving “surprise” medical bills. 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.
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.
What facilities and services are covered under the No Surprises Act?
The No Surprises Act applies when you receive most emergency services and non-emergency services. Emergency services refer to emergency rooms at a hospital, independent emergency departments and any department of a hospital where you might get post-stabilization services. Post-stabilization services are procedures you might need to stabilize your condition after an emergency. Non-emergency services are also included and they cover hospital, hospital outpatient departments and ambulatory surgical centers. It also applies to out-of-network providers at in-network facilities and services from out-of-network air ambulance service providers. In addition, it also establishes an independent dispute resolution process for payment disputes between plans and providers.
Does the No Surprises Act cover me if I do not have health insurance?
Usually, if you do not have or use health insurance to pay for your care, providers must still abide by the No Surprises Act. In summary, they must give you a “good faith” estimate of how much it will costs (except in cases of emergency care) BEFORE you get care. You should get the estimate when you schedule care at least three business days in advance. This requirement should be followed if you ask for one and even if you don’t. 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.
Can I waive my protections under the No Surprises Act?
According to the Centers for Medicare & Medicaid Services, if you have health insurance, out-of-network providers or emergency facilities may ask you to sign a notice and consent form before providing certain 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 protection 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.
Summary
These and other pertinent factors of the No Surprise Act can be explored at the cms.gov/medical-bill-rights website. These consumer-friendly web pages are now available for people with easy-to-read information and actionable guidance to help people understand their rights. The webpages’ design and content were informed by human-centered design research and user testing with patients, caregivers, patient advocates, and others. When people visit the consumer website, they’ll be guided through:
- Understanding their rights under the No Surprises Act, including out-of-network billing protections and good faith estimates for future care
- Identifying actions they can take to exercise their rights and find a resolution if they receive an unexpected medical bill, using a Q&A tool that asks about their situation
- Submitting a complaint if they think their provider, facility, or insurance company didn’t follow the rules of the No Surprises Act through an optimized process and redesigned form
- Disputing a bill if they are uninsured or didn’t use insurance and they were charged more than their good faith estimate
- Finding guides that will help them navigate medical billing questions, as well as learning how to connect with the No Surprises Help Desk
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