Federal No Surprise Act offers the insured and uninsured protections from surprise medical bills

Kaleah Mcilwain

Attorney General Brian E. Frosh announced the protections consumers get under the new No Surprise Act that went into effect on Friday, January 1, 2022.

The No Surprise Act guarantees that when consumers receive out-of-network emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center they will not receive any surprise bills or balance billing.

A surprise bill is unexpected balance bill, often from a provider that the patient didn't choose, after the patient receives care from an out-of-network provider or at an out-of-network facility. Balance billing is when the patient is billed for the difference between the amount the provider charges and the amount the patient's health plan covers.

This act does not apply to those with coverage through programs like Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE because these programs have other protections against high medical bills.

Under the new No Surprise Act when receiving emergency services from an out-of-network provider or facility they cannot bill the patient for more than the in-network cost-sharing amount (deductible, copayment, and coinsurance) of their health plan.

Also, when a patient receives services from an in-network hospital or ambulatory surgical center, certain providers at the facility may be out-of-network. In those cases, the most those providers may bill the patient is their health plan’s in-network cost-sharing amount.

With the No Surprise Act in effect patients are never required to give up their protections from surprise and balance billing and they do have to get out-of-network care. Patients can choose a provider or facility in their plan’s network.

There are additional protections for members of Health Maintenance Organizations (HMOs), as well as PPO and EPO members.

For patients who are uninsured the No Surprise Act requires providers and facilities to inform those patients through a good faith estimate in advance how much their health care will cost them. There is a new dispute resolution process for bills that are at least $400 more than what the patient expected from the good faith estimate they received.

The Attorney General’s Health Education and Advocacy Unit (HEAU) should be contacted if a patient has received a surprise medical bill or if a patient receives a bill that is higher than their good faith estimate.

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