The No Surprises Act protects people from “surprise medical bills.” These protections apply to anyone enrolled in a private health insurance plan, including employer plans or a plan purchased on or off the marketplace. New protections were added in 2022 to restrict excessive out-of-pocket costs from emergency and non-emergency services. If you’re uninsured or you decide not to use your health insurance, these protections allow you to get a good faith estimate of the cost of your care up front, before your visit. If you disagree with your bill, you may be able to dispute the charges.
Even though surprise bills are now banned in many circumstances, enrollees should monitor their medical bills because they might need to take action to protect their rights. Note: Most of the law’s protections only apply to people with private insurance, and not to people who are uninsured or enrolled in Medicaid, CHIP, or Medicare.
New protections for insured patients
The new law protects insured people in two major ways:
- For emergency care: An insured person can get care at any emergency department, even if the care is out of network. The out-of-network emergency facility, and the doctors and other providers who treat the patient, cannot bill the patient for more than in-network cost-sharing amounts (i.e., deductible, copay, coinsurance). The plan also must apply only in-network cost-sharing.
- For non-emergency care: If the insured person goes to an in-network facility, they cannot be billed for more than the in-network cost-sharing amount for their services, even if they receive care from an out-of-network provider.
Note: Out-of-network ambulance services are not covered by the No Surprises Act and can still lead to high bills.
Key terms
- In-network providers: Facilities and doctors who contract to accept a payment rate with your insurer. In-network care generally costs less than care that is out-of-network. You might still have to meet a deductible before your insurance pays the bill, or you might owe a copayment or coinsurance, depending on the type of service and your health plan.
- Out-of-network providers: Providers who do not contract with your insurer and instead charge you separately for their services. Unlike in-network providers, out-of-network providers set their own charges. Your health plan might cover some of the cost but often covers none of the cost of out-of-network services.
- Surprise medical bill: An out-of-network medical bill a person receives from an out-of-network provider for emergency services, or for non-emergency care while at an in-network facility.
Frequently Asked Questions
Generally, people enrolled in private insurance are responsible for checking their plan’s network before getting health services to ensure that the medical provider they’ve selected is in-network. In most situations, people who get medical services from an out-of-network provider are responsible for paying the out-of-network medical bills they receive. Most plans pay less for out-of-network care than they would pay for in-network care, and some don’t cover out-of-network bills at all, leaving the enrollee responsible for paying most or all the out-of-network bill.
There are some situations where a person doesn’t get to choose their medical provider and ends up receiving out-of-network care. This can happen in medical emergencies when people are taken to the closest ER. It can also happen when people select an in-network hospital for scheduled care but receive care from an out-of-network doctor they did not get to pick (such as the anesthesiologist). These scenarios are common. An out-of-network medical bill a person receives after getting care from an out-of-network provider they didn’t get to choose is known as a surprise medical bill.
If you don’t have insurance or choose not to use it, these new rules make sure you get a “good faith estimate” of how much your care will cost, before you get care. They also allow you to file a dispute if you are charged more than $400 above the estimate.
Any health care provider in any emergency department or at the insured person’s in-network facility must follow the new law. A “provider” is defined broadly to include doctors, radiologists, therapists, and others. Services like imaging and lab work, preoperative and postoperative services, telemedicine, and equipment and devices are also covered. “Facilities” are hospitals, hospital outpatient departments, and ambulatory surgery centers. They don’t include other settings, such as urgent care.
The first step is to check with the insurance company to see if the provider made a mistake. The out-of-network provider shouldn’t bill for more than the in-network cost-sharing amount for the service(s) indicated on the Explanation of Benefits (EOB). If there is no EOB it might mean that the provider didn’t contact the insurance company as required.
The second step is to contact the out-of-network provider and ask them to correct the bill. Providers can face fines up to $10,000 per violation for not following the new rules.
If the provider refuses to resolve the issue by correcting the bill, then it might be necessary to file a complaint by calling the No Surprises Help Desk at 1-800-985-3059. The No Surprises Help Desk is also available for people who have questions or want more information about the new rules. Consumers can also file complaints online at www.cms.gov/nosurprises.
A mistake made by a person’s insurance company could also result in a surprise medical bill. If that happens, the person should call their insurance company, explain the situation, and ask them to treat the claim as a surprise medical bill. If the insurance company doesn’t correct the issue, the next step is to file an appeal with the insurance company. If this is unsuccessful, the next step is to request an external appeal.
Note: Every EOB a person receives is required to include instructions for how to file an appeal.
In North Carolina, the Consumer Services Division of the Department of Insurance can help people file appeals and resolve billing and coverage problems, including surprise medical bills.
Services that are scheduled in advance directly with an out-of-network provider are not covered under the new law, and the provider can charge patients the full cost for services.
Cost-sharing charges can vary widely across insurance plans, which means that a person could still receive very high medical bills due to their plan’s standard in-network cost-sharing charges being high. These kinds of bills are not considered surprise medical bills.
More Resources:
No Surprises Act, Centers for Medicare and Medicaid Services (CMS)
Overview of rules & fact sheets | CMS
Consumers: new protections against surprise medical bills |CMS
