The No Surprises Act, which went into effect on January 1, 2022, makes it illegal forl insured patients to be billed for more than their in-network rate for costs resulting from two common scenarios associated with unexpected medical bills:
- Emergency-related care – including diagnosis and treatment to help stabilize the patient, plus air (but not ground) ambulance services: and
- Treatments from out-of-network providers at in-network facilities (including hospitals, hospital outpatient departments and ambulatory surgical centers).
Below are additional details about these and other patient protections, important to people with MS, in the No Surprises Act.
Although the No Surprises Act provides patients with additional protections, it is still recommended that people in need of health care services utilize in-network doctors, hospitals, and other providers when possible. Seeking in-network services is the most cost-effective way to receive care.
What is a Surprise Bill?
A surprise bill is an unexpected request for payment from an out-of-network health care professional or facility for services rendered. They are also referred to as “balance bills” because the amount of the bill reflects the difference, or balance, between their insurer’s in-network rate for that service and what the out-of- network provider is charging.
Who or What Types of Insurance do the Protections in the No Surprises Act Apply to?
The surprise billing protections apply to most Americans with health insurance from a job-based or another group plan, as well as policies purchased from the ACA Marketplace or an insurance company directly. Medicare, including Medicare Advantage, and Medicaid beneficiaries already have protections from surprise bills. However, those who are on short-term plans are NOT
covered by this law.
The protections in the No Surprises Act apply to emergency services, air ambulances, and certain non-emergency services furnished by out-of-network providers in an in-network hospital, hospital outpatient department, or ambulatory surgical center, including services (such as lab work, radiology, and anesthesiology) related to the emergency.
What Surprise Bills does the Act Prevent?
The law prevents out-of-network providers from billing patients more than in-network cost-sharing amount (balance billing) for:
What Other Protections does the Act Include?
- all out-of-network emergency services.
- post-stabilization care at out-of-network facilities until a patient can be safely transferred to an in-network facility.
- air ambulance transport in both emergency and non-emergency situations.
- NOTE: The Act does not cover ground ambulance transportation
- Non-emergency services by certain types of providers, unless a notice and consent process is followed.
- • radiology and anesthesiology services as these providers must be covered as in-network.
Does the No Surprises Act Apply to Urgent Care Facilities?
- 90-day continued coverage if your provider moves out of network - If your provider moves out-of-network, your insurer must provide 90 days of coverage for that provider at the in-network rate. This allows time to find a new provider to meet your needs.
- More accurate provider directories - Your insurer must maintain and update their provider directory every 90 days and insurers must respond to requests for this information within one business day. Additionally, if your insurer incorrectly tells you that a provider is in-network, they must provide in-network coverage.
- Advanced notice on costs on out-of-network care.
- If a patient inquires if a provider is in-network, an insurer must reply within three business days and include a good-faith estimate of what the plan will pay and what the patient’s out-of-pocket costs will be.
- An out-of-network provider or facility must provide a written notice of estimated charges to the patient 72-hours before providing services. This notice must include a good faith estimate of out-of-network charges. (Please note that radiologists and anesthesiologists must stay at the in-network rate. If you receive an out-of-network notice from these providers, please notify your insurer)
Protections vary due to state laws but, generally, the Act covers emergency services provided by some, but not all, urgent care facilities. You can still receive a balance bill for non-emergency services provided by these facilities.
What Should You Do if You Receive a Surprise Bill?
The No Surprises Act specifies that providers cannot send you a surprise bill for certain services. If you receive a surprise bill for the services outlined above, you should call your insurer or health plan administrator to report it and clarify how much you owe, if anything. Try to avoid paying for a surprise bill until your insurer or health plan administrator has clarified the amount you owe and why.
For more information, please visit www.cms.gov/nosurprises