No Surprises Act

Learn about new rights and protections to end surprise bills, better understand costs before getting health care, and minimize payment disagreements.

 

Your Rights and Protections Against Surprise Medical Bills

 

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

 

What is “balance billing” (sometimes called “surprise billing”)?
 

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is calledbalance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

 

You’re protected from balance billing for:
 

Emergency services If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other types of services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

 

You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.

 

State Specific Rules

In the state of Florida, there are comprehensive balance billing protections in addition to those provided by the federal No Surprises Act. Florida law states that insurance companies are not allowed to bill you for amounts beyond your plan’s in-network cost-sharing amount. That protection applies to HMO and PPO insurance plans for emergency services by out-of-network providers and facilities, as well as non-emergency services provided by out-of-network providers at in-network facilities. For PPOs, the state payment standard applies to emergency services and non-emergency services provided by out-of-network providers at in-network facilities. For HMOs, the state payment standard only applies to emergency services but the state also has a claim dispute resolution program in place. Under Florida law, these protections do not apply to ground ambulance services for PPO insurance plans, patients enrolled in PPO insurance plans who consent to non-emergency out-of-network services, and patients with self-funded insurance plans. The laws put in place by the state of Florida work together with the requirements of the No Surprises Act to ensure that you are protected from surprise medical bills. 

 

Florida Department of Financial Services, Division of Consumer Services
1-877-MY-FL-CFO

Georgia law generally contains balance billing protections similar to those under the No Surprises Act (as described in this Notice), for individuals enrolled in fully funded commercial plans, such as preferred provider (“PPO”) plans, and health maintenance organization (“HMO”) plans. If you have one of these plans, Georgia also extends the balance billing protections to covered emergency and non-emergency medical services provided by nonparticipating providers in participating birthing centers, diagnostic and treatment centers, hospices or similar institutions.

 

If you have a Georgia PPO or HMO plan and think you’ve been wrongly billed by your health care provider, you may file a complaint with the Georgia Consumer Protection Division by calling (404) 651-8600 or visiting https://consumer.georgia.gov/resolve-your-dispute/how-do-i-file-complaint 


If you believe you have received an improper bill from your health plan, you may file a complaint with the Office of Commissioner of Insurance and Safety Fire by emailing consumercomplaints@oci.ga.gov or visiting https://oci.georgia.gov/file-consumer-insurance-complaint

Nevada law protects patients covered by health benefit plans regulated by the state, the Public Employees’ Benefits Program, and third parties that opt into the prohibition from balance billing for medically necessary emergency services provided by an out-of-network provider.
Additionally, Nevada law requires that the patient pay only their in-network cost-sharing amounts. This law does not apply to: (1) any patient who has coverage through an out of state insurance policy; (2) critical access hospitals or any medically necessary emergency services provided at such a hospital and (3) any out-of-network healthcare services provided 24 hours after notification that a patient has been stabilized.

 

Department of Business and Industry, Nevada Division of Insurance
1-888-872-3234
Visit https://doi.nv.gov/Consumers/Health_and_Accident_Insurance/Balance_Billing_FAQs for more information about your rights under Nevada law.

New Mexico protects patients from balance billing when patients receive: (i) emergency services from an out-of-network provider or provided at an out-of-network facility; (ii) covered non-emergency services provided by an out-of-network provider at an in-network facility if the patient did not have the ability or opportunity to choose an in-network provider; and (iii) medically necessary care from an out-of-network provider when an in-network provider is unavailable within a patient’s network.

Additionally, New Mexico law states that if a patient chooses to receive non-emergency care from an out-of-network provider, the balance billing protection does not apply. These protections only require patients to pay their in-network cost-sharing amounts. This protection applies to any entity subject to New Mexico’s insurance laws.

 

New Mexico Office of Superintendent of Insurance, Managed Care Bureau
www.OSI.state.nm.us  1-855-4-ASK-OSI

Texas law protects patients with state-regulated health insurance (about 16 percent of Texans) from surprise medical bills in emergencies or when they didn’t have a choice of doctors. The law bans doctors and providers from sending surprise medical bills to patients in those cases. Texas law also prohibits balance billing for any health care, medical service, or supply provided at an in-network facility by an out-of-network physician or other provider and for services by diagnostic imaging providers and laboratory service providers provided in connection with a health care service performed by a network physician or provider.

 

Texas Department of Insurance 
Consumer Help Line: 1-800-252-3439 
Visit https://www.tdi.texas.gov/tips/texas-protects-consumers-from-surprise-medical-bills.html or https://www.tdi.texas.gov/medical-billing/surprise-balance-billing.html for more information about your rights under Texas law.

When balance billing isn’t allowed, you also have these protections:

 

  • You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
  • Generally, your health plan must:
  • Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
  • Cover emergency services by out-of-network providers.
  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
  • Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.
If you think you’ve been wrongly billed, contact 1-800-985-3059. Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost

 

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
  • Make sure your health care provider gives you a Good Faith Estimate writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
  • If you receive a bill that is at least $400 more than your Good FaithEstimate, you can dispute the bill.
  • Make sure to save a copy or picture of your Good Faith Estimate.
 
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.

For Your Good Faith Estimate, Contact:

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Inquiry@cpllabs.com

Phone: 800.633.4757