Avoid Surprise Healthcare Expenses: How the No Surprises Act Can Protect You

Have you ever:

• Visited the emergency room for treatment, only to receive a surprise bill?
• Had major surgery performed at an in-network facility that was covered by your health plan, only to receive an unexpected bill from an out-of-network anesthesiologist?
• Been injured in an accident and received a surprise bill for the air ambulance ride to the hospital?

If so, you are not alone. So many people in the U.S. face unexpected medical bills, especially after an emergency situation. That's why the federal No Surprises Act was enacted: to provide protections against these surprise bills and to reduce healthcare costs.

What is surprise billing?

Surprise billing occurs when you have health coverage and unknowingly or unavoidably receive care from an out-of-network provider or at an out-of-network healthcare facility and are billed directly for that care when your health plan does not cover the entire cost of care.

In the past, in addition to any out-of-network cost-sharing that you would be responsible for (like coinsurance or copayments), the out-of-network provider or healthcare facility could bill you directly for the difference between their billed charge and the amount your health plan will to pay for the charge (the "allowed amount"). This is called "balance billing."

For example, if an out-of-network provider charged you $1,000 for a service, and your health plan's allowed amount for that service was $250, you could have been billed for the remaining $750, in addition to any cost-sharing you may owe on the allowed amount.

The No Surprises Act offers new protections. What are they?

In general, you are protected from surprise billing for:

• most emergency services (including emergency mental health services),
• non-emergency services from out-of-network providers at certain in-network healthcare facilities (hospitals, hospital outpatient departments, or ambulatory surgical centers), and
• services from out-of-network air ambulance service providers.

You are also protected from disputes over payment for these services between plans/insurers and providers/facilities, so that you're not in the middle.

Do these protections apply to me?

Yes, if you have a health plan that you get through your job or if you purchased a plan yourself.

The No Surprises Act does not apply to certain health coverage, including:

• short-term, limited-duration insurance plans,
• excepted benefits plans (such as standalone dental and vision coverage),
• retiree-only plans, or
• account-based group health plans.

Does the law cover me in all situations?

The No Surprises Act covers most emergency services, non-emergency services from out-of-network providers at certain in-network healthcare facilities, and services from out-of-network air ambulance service providers.

It does not cover every unexpected or high medical bill.

For example, you can still be billed for services and treatments that are not covered by your plan. The No Surprises Act's surprise billing protections do not apply to non-emergency services provided by an out-of-network provider at an out-of-network facility.

You may also give up surprise billing protections in certain non-emergency situations if you receive notice and provide consent to waive these protections.

What does the No Surprises Act do?

If you are in a covered plan (see Do these protections apply to me, above), the law:

• bans surprise bills in most emergencies, even when treatment is provided outside of your plan's network and without prior authorization. Your health plan cannot deny coverage because you did not get plan approval before heading to the emergency room.
• limits cost-sharing for most emergency services outside of your plan's network and for most non-emergency services provided in an in-network healthcare facility by an out-of-network provider.
• requires patient consent to waive surprise billing protections for certain circumstances.
• generally bans out-of-network providers from balance billing patients for ancillary services (like anesthesiology, pathology, radiology, or neonatology) they provide during a visit to an in-network healthcare facility. These types of providers cannot ask you to consent to waiving your surprise billing protections.
• requires that providers and facilities give you a notice explaining the billing protections and who you should contact if you think the protections have been violated.

What if my plan has a closed network and does not include out-of-network coverage?

Even if your plan has a closed network and otherwise does not provide coverage for out-of-network items or services, the No Surprises Act protections apply if the services are covered in-network under your plan.

Will my payments count toward the plan's deductible and out-of-pocket maximums?

A plan cannot require more cost-sharing for out-of-network emergency services, non-emergency services received at an in-network healthcare facility, and air ambulance services than it does for equivalent in-network medical services.

Any cost-sharing payments you make must count toward your in-network deductible or out-of-pocket maximums as if an in-network provider charged them.

Examples

• While walking your dog, you slip on ice, hit your head, and break your arm, requiring you to visit the nearest emergency room. The doctor orders imaging, radiology, and determines that the severity of the injury requires same-day surgery.

  Even if you received this emergency care from an out-of-network provider or healthcare facility, you are only responsible for paying your in-network deductible, copayments, and coinsurance.

• To rule out cancer, you schedule a surgical biopsy to remove tissue from your breast. Both the hospital and the doctor performing your surgery are in-network. However, you do not know if the providers administering your anesthesia and examining the tissue are also in-network.

  Ancillary out-of-network expenses will be at the in-network rate if your healthcare facility is in-network. This includes services from providers such as anesthesiologists and pathologists.

• During an intense exercise session, you experience sharp chest pains that require a trip to the nearest emergency room. Following a brief exam, the doctor determines you must be transported by air ambulance to a different hospital that specializes in cardiology.

  If your plan covers air ambulance services, the No Surprises Act protects you even if the air ambulance company is not in-network. Your responsibility will be the deductible, copayment, or coinsurance you would have paid if the air ambulance had been in-network. However, if your plan does not cover air ambulance services at all or if a ground ambulance transports you, then you may be responsible for the uncovered amount.

What is the notice and consent exception, and how does it apply?

Under the No Surprises Act, a provider or facility can ask individuals to voluntarily waive their balance billing protections and cost-sharing limitations in certain circumstances.

A provider or facility can provide you with a notice and consent form and ask you to waive surprise billing protections when:

• you schedule certain non-emergency services (other than ancillary services) at an in-network healthcare facility, or
• you need post-stabilization care after an emergency and your healthcare provider or facility is out-of-network.

Example

• You sustained a shoulder injury while playing football. An X-ray shows your shoulder is both broken and dislocated. A colleague recommends an orthopedic surgeon. Your surgery is scheduled 2 weeks in advance at an in-network hospital.

  The same day you schedule your surgery, you receive a notice informing you that your surgeon is not part of your health plan's network. To proceed with surgery, you must consent to waive your balance billing protections. Due to your preference for this doctor, you sign the consent form.

  You are liable for any balance bill you receive. You signed the consent form acknowledging that your surgeon was out of network more than 72 hours before your surgery date.

  However, if the surgeon had not provided you the consent form within the minimum 72 hours before the services, the surgeon could not balance bill you for the services provided during your surgery.

When is notice and consent not allowed?

In emergency situations, notice and consent is not permitted when providing:

• any emergency services before your condition is stabilized
• items or services due to unforeseen urgent medical needs
• post-stabilization services if certain additional requirements are not met

In non-emergency situations, notice and consent is not permitted for ancillary services, which are defined as items and services that are:

• related to emergency medicine, anesthesiology, pathology, radiology, and neonatology, whether provided by a physician or non-physician practitioner
• provided by assistant surgeons, hospitalists, and intensivists
• diagnostic services, including radiology and laboratory services
• provided by an out-of-network provider if there is no in-network provider available
• provided during treatment due to unforeseen, urgent medical needs

What information is included on the notice and consent form?

The notice and consent documents, which are standardized by the Federal Government, describe the No Surprises Act protections against unexpected medical bills and ask if you are willing to give up those protections and pay more for out-of-network care. By signing the consent form, you are giving up those protections. The form will also give you an estimate of out-of-network costs.

If the notice and consent is for post-stabilization services, it should also include a list of in-network providers who can provide post-stabilization care.

The notice and consent documents must be given physically separate from other documents. They may not be attached to or incorporated into any other documents. Providers and healthcare facilities must provide you or your authorized representative with the choice to receive the notice and consent document in any of the 15 most common languages in the state or region where the facility is located.

Do I have to sign the notice and consent form?

No. Signing this form is entirely your choice. You should only sign the form if you agree to give up surprise billing protections for the items and services specifically named in the notice. You will probably pay more if you choose to receive care outside of your network. Before signing, read the form carefully, and weigh your options!

If you do not sign, then the provider may decide not to provide the non-emergency or post-stabilization care included in the notice. You may need to find and reschedule with an in-network provider or facility. Your health plan can help you find one.

If you do not sign the notice and consent form and the provider or facility still provides care to you, then the No Surprises Act protections continue to apply.

What about state law? Can it protect me from surprise medical bills?

There are some states with additional balance billing protections than those required under the No Surprises Act. Look up your state's Department of Insurance website for more information about the No Surprises Act and laws that may apply to your coverage.

Are medical bills and Explanations of Benefits the same?

No. Before receiving a medical bill from your provider's office, you should receive an Explanation of Benefits (EOB) from your health plan.

The EOB tells you what services you got, when you got them, how much your plan will pay, and how much you owe. This is key information to help you determine if you received a surprise bill. Check your EOB for mistakes, and review it every time.

If you are still waiting for an EOB from a recent visit and you receive a bill from a provider, contact your health plan to determine if the provider sent them a claim.

What should I do if I get a surprise bill?

Contact the No Surprises Help Desk at (1 800) 985-3059 if:

• you receive a bill that exceeds what the EOB shows you owe in cost sharing
• you have any questions about the No Surprises Act rules
• you believe that the No Surprises Act is not being followed

You can reach the help desk from 8 a.m. - 8 p.m. Eastern Time (ET) Monday through Friday and from 10 a.m. - 6 p.m. ET on Saturday and Sunday.

If you want to file an online complaint, visit the No Surprises Medical Bill Rights web page.

The No Surprises Help Desk cannot require the provider or facility to adjust their charges, make any medical or legal judgments, or determine the value of the claim.

What steps should you take if your plan denies coverage?

Carefully read your EOB. You can file an internal appeal with your plan if your EOB shows that it did not cover an item or service consistent with the No Surprises Act.

• Call your plan and ask for a copy of the plan's internal appeals procedure and what information and documents to include with your internal appeal request.
• Then, submit your internal appeal in writing. Your plan must respond promptly.

Visit the U.S. Department of Labor's publication, Filing A Claim for Your Health Benefits.

Resources

You can learn more about the No Surprises Act and your health plan's compliance with the requirements.

U.S. Department of Labor's Employee Benefits Security Administration (EBSA)

• Call a benefits advisor toll-free at (1 866) 444-3272.
• Visit EBSA's No Surprises Act web page.

The No Surprises Help Desk

• Call 1-800-985-3059.
• Visit the No Surprises Medical Bill Rights web page.

Your state's department of insurance website and contact information

You can find your state's information on the National Association of Insurance Commissioners website.