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July 11, 2022

What You Should Know About Surprise Billing

This year, the federal No Surprises Act (NSA) took effect. It protects patients from paying surprise medical bills for emergency care and care received at in-network facilities.  

Patients will not have to pay higher out-of-network costs for covered services. Medical providers cannot bill patients more than their in-network cost-sharing amount for emergency services or for care at in-network facilities.  

What is surprise billing? A surprise bill happens when a patient unknowingly or unavoidably receives health care from providers outside their insurance company’s network and is billed directly for that care. 

What does the No Surprises Act cover?  

• Surprise bills for covered emergency out-of-network services, including air ambulance services (but not ground ambulance services). 

• Surprise bills for covered non-emergency services at an in-network facility. 

 What else should I know?  

• You can find more information at: https://www.cms.gov/nosurprises/consumers 

• Your health plan and the facilities and providers that serve you must send you a notice of your rights under the new law.  

• If you’ve received a surprise bill that you think isn’t allowed under the new law, you can file an appeal with your insurance company or ask for an external review of the company’s decision. You also can file a complaint with your state department of insurance or with the U.S. Department of Health and Human Services (HHS).  

• An independent dispute resolution (IDR) process, or another process your state sets up, is available to settle bills. Providers and insurance companies can use this process to settle disputes about your bill without putting you in the middle. In certain circumstances, a similar dispute resolution process is available for individuals who are uninsured, such as when the actual charges are much higher than the estimated charges. 

• The IDR process applies to people who have private health plans, including plans through an employer or purchased on their own. The IDR process does not include individuals covered through Medicare or Medicaid.  

• You still can agree in advance to be treated by an out-of-network provider in some situations, such as when you choose an out-of-network surgeon knowing the cost will be higher. The provider must give you information in advance about what your share of the costs will be. If you did that, you’d be expected to pay the balance bill as well as your out-of-network coinsurance, deductibles, and/or copays. 

 

 

About the National Association of Insurance Commissioners

As part of our state-based system of insurance regulation in the United States, the National Association of Insurance Commissioners (NAIC) provides expertise, data, and analysis for insurance commissioners to effectively regulate the industry and protect consumers. The U.S. standard-setting organization is governed by the chief insurance regulators from the 50 states, the District of Columbia and five U.S. territories. Through the NAIC, state insurance regulators establish standards and best practices, conduct peer reviews, and coordinate regulatory oversight. NAIC staff supports these efforts and represents the collective views of state regulators domestically and internationally.