Emergency room visits are stressful enough. So, you don't need or want the added stress of receiving an unexpectedly high bill. This has happened to people who went to the ER and were treated out of their network plan. Some people didn't realize they were out of network until the bill was handed to them. But there's a new law that protects you from those surprise bills.
No Surprises Act Effective 2022
Effective Jan. 1, 2022, the No Surprises Act was part of the 2020 Coronavirus relief package. It was enacted July 1, 2021, through the Biden-Harris Administration. The new rule was designed to provide billing protections to individuals who were covered under individual or group medical plans but received treatment out of network.
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These covered people would often receive surprise medical bills for emergency care or nonemergency healthcare from out-of-network providers at a network hospital. It also addressed services from out-of-network air ambulance services.
According to a report from the Peterson-Kaiser Family Foundation, in 2017, one in five emergency claims resulted in at least one out-of-network charge. One-in-six network hospitalizations also provided care out of an individual's insurer's network. The price to patients racked up to thousands of dollars.
The No Surprises Act gave patients and their families a way to avoid or at least fight these non-network bills.
Protections Provided to Insured Patients
There are several protections provided by the No Surprises Act. One is banning most emergency services bills that are out of network even if you didn't get prior authorization.
It also banned out-of-network co-insurance or cost-sharing. The insurance company can't require the individual to pay more than a copay they would have for an in-network provider.
Balance bills for out-of-network services are also banned from an out-of-network doctor or other health care providers. For instance, if you go to an in-network ER and need a radiologist, even if she is out of the network, you won't have a balance bill.
The No Surprises Act also required an ER or in-network facility to explain billing for non-network providers in advance of treatment. You are not required to sign anything.
Uninsured Patients Protections
If you are uninsured or want to self-pay, the facility must give you a "good faith" estimate of all costs. This estimate must be provided to you before treatment begins.
If your medical bill is more than $400 higher than your good faith estimate, you can file a dispute. This must be done within 120 days of the issued bill's date.
Americans Can Go to Arbitration
The independent dispute resolution (IDR) is an arbitration process that can be used. But it can only be used if you and the health insurance company cannot reach an agreement after 30 days of negotiations. If after 30 days the dispute isn't resolved, either party can initiate the IDR process. An IDR arbitration administration cost is $50 per party.
Each party is required to submit supporting documentation and payment offers to the arbitrator. The arbitrator's decision is binding. At that point, the party who lost the arbitration must pay both party's administration costs.
No Surprises Act Exceptions Existed
Some insurance companies had previously provided protection from balance billing and continue to provide protection. They are Medicare, Medicaid, TRICARE, Indian Health Services and the Veterans Health Administration.
States With No Surprises Act Laws
The federal act doesn't supersede a state's current law. But this is only if the state's law provides the same protection against balance and related higher cost-sharing (co-insurance) as the federal act.
If the state has an arbitration process that is comparable or better than the federal IDR, the state supersedes the federal IDR. The federal IDR will not arbitrate the case.
- CMS: Surprise Billings and Protecting Consumers
- CMS: New Protections for You
- KFF: The No Surprises Act Begins January 2022: This is What You Can Expect
- CMS: No Surprises: Understand Your Rights Against Surprise Medical Bills
- Healio: No Surprises Act Faces Multiple Lawsuits Against Billing Dispute Provision
- CMS: What You Need to Know About the Biden-Harris Administration’s Actions to Prevent Surprise Billing
- SHRM: New Rule Initiates Health Care ‘Surprise Billing’ Arbitration