Patient Protections from Surprise Medical Bills in the “No Surprises Act”

There’s nothing worse than receiving an unexpected medical bill. It’s the worst kind of surprise.

You might have received an unexpected “balance bill” for medical services from a provider that, usually unknown to you, is out of network. A balance bill provides the difference between the provider’s billed charges and the amount collected from the plan and from the patient in the form of cost sharing (such as a copayment or deductible amount). Surprise medical bills often arise when an individual does not have the opportunity to select an in-network provider, such as in a medical emergency. For nonemergency care, an individual might choose an in-network facility or an in-network provider, but not know that a provider involved in their care (e.g., an anesthesiologist or radiologist) is an out-of-network provider.

The “No Surprises Act” (NSA) was enacted on December 27, 2020, as part of the Consolidated Appropriations Act of 2021 (CAA) to increase health care transparency and protect consumers from surprise medical bills. Effective for plan years beginning on or after January 1, 2022, the NSA provides federal protections against surprise medical billing by limiting out-of-network cost sharing and prohibiting “balance billing” in many of the circumstances in which surprise medical bills arise most frequently.

The NSA’s protections for surprise medical billing apply to group health plans and health insurance issuers offering group or individual health insurance coverage. The Departments of Labor, Health and Human Services, and the Treasury (Departments) have issued guidance detailing how health plans and issuers determine provider payment amounts for services subject to the NSA’s balance billing protections. If the parties cannot agree on a payment amount, they can use the NSA’s federal independent dispute resolution (IDR) process to resolve the dispute.

The NSA’s surprise medical billing protections apply to the following services:

Emergency services received in a hospital’s emergency department or an independent freestanding emergency department
Nonemergency services provided by an out-of-network provider at an in-network facility
Air ambulance services provided by an out-of-network provider

In addition, the NSA provides the following protections for covered services:

Limits cost sharing for out-of-network services to in-network levels
Requires the cost sharing to count toward any in-network deductibles and out-of-pocket maximums
Prohibits balance billing in most situations

However, these protections don’t apply in all situations. For example, these new billing protections generally don’t apply to services covered by vision- or dental-only plans. However, if the health plan includes dental or vision benefits, these protections could apply to dental or vision services covered by the health plan. The balance billing protections also do not generally apply to ground ambulance services.

Some health insurance coverage programs already have protections against high medical bills and surprise medical billing if covered through Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE. The new rules don’t apply to these programs.

If you are faced with a surprise high-dollar medical bill, your ARC representative is available to help. We can advocate on your behalf and ensure you are receiving the lowest costs for your services possible. Contact us today to learn more.

Resources

Interim final rules from July 13, 2021, prohibiting balance billing for items and services subject to the NSA’s protections

Interim final rules from Oct. 7, 2021, implementing the federal IDR process

Final rules from Aug. 26, 2022, addressing certain issues related to the federal IDR process and payment disclosures

Model notice for surprise medical billing

No Surprises: Understand your rights against surprise medical bills (PDF)

https://www.cms.gov/nosurprises/consumers/new-protections-for-you