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What you need to know

The No Surprises Act for Patients

The No Surprises Act (NSA) prohibits surprise billing for many out-of-network healthcare services, including most emergency situations. However, there will still be situations where patients will not be protected.

When are Patients Protected

Protections for patients include these types of services:

1

Out-of-network emergency care at an emergency facility

2

Out-of-network care at an in-network facility

3

Air ambulance services

What the No Surprises Act Means for Patients

The No Surprises Act provides protections for patients who receive health care benefits from their employers or who are enrolled in individual health plans. For services that fall into these protected categories, providers will not be allowed to bill you for amounts higher than what you would pay from an in-network provider. Any out-of-network care costs in these types of situations will be applied to your in-network deductible and your out-of-pocket max.

You are also protected from surprise billing if you need an air ambulance; again, you will only be responsible for what you would pay for a similar in-network service. It’s important to note, however, that the NSA does not protect patients from balance billing for ground ambulance services.

What the No Surprises Act Does Not Cover

In general, if a patient chooses to receive care out-of-network, The No Surprises Act will not apply.

So, if you choose to see a doctor or specialist who is not in-network, The No Surprises Act and its protections will not apply, and you may face much higher costs than your health plan’s in-network rate.

The No Surprises Act also does not protect patients from balance billing for ground ambulance services, or when the law’s notice and consent requirements are met.

FAQs

The No Surprises Act prohibits out-of-network providers from pursuing members directly for surprise medical bills in situations where the patient has little or no control over who provides their care. This includes all emergency services (except ground ambulances), or when an out-of-network provider is involved in their care while they are at an in-network facility. As a result, patients will be protected from surprise bills in most situations where they have little or no control over who provides their care.

However, the No Surprises Act does not apply if the member chooses to receive items and services from an out-of-network provider. The law also does not apply for ground ambulance services, or when the law’s notice and consent requirements are met for certain non-ancillary services provided at in-network facilities.

The No Surprises Act also establishes an Independent Dispute Resolution (IDR) process, also referred to as arbitration, to resolve disputes between OON providers and insurers/health plans.

Under the law, effective upon plan years beginning on or after January 1 2022, out-of-network providers are prohibited from pursuing members directly for surprise medical bills in situations where they have little or no control over who provides their care, like for all emergency services (except ground ambulance), or when an out-of-network provider is involved in their care while they are at an in-network facility.

If a patient receives a service that is covered by the No Surprises Act, the law caps the patient’s cost share to what it would be if the services were provided in-network.

Patients are protected from surprise bills when you receive:

  • Out-of-network emergency services, including air ambulance (but not ground ambulance)Covered medical items and services performed by an OON provider at an INN facility (unless the provider follows the notice and consent process described above).
  • Out-of-network non-emergency, ancillary services* provided at in-network facility.
  • Non-emergency, non-ancillary services provided at in-network facility, and the provider did not get your prior consent in the way the No Surprises act requires.

 

And, for the above services, your health plan must ensure your cost-share (in other words, your coinsurance, copay, deductible):

  • Is the same as it would have been if the service was provided in-network.
  • Is based on what your plan would pay an in-network provider.
  • Counts toward your in-network deductible.
  • Counts toward your out-of-pocket maximum.

 

*Ancillary services include services related to emergency medicine, anesthesiology, pathology, radiology and neonatology; certain diagnostic services (including radiology and laboratory services); items and services provided by other specialty practitioners; and items and services provided by an out-of-network provider if there is no in-network provider that can provide that service.

Remember: In-network providers are not allowed to balance bill. If you are asked to give up your protections against surprise billing through the Notice and Consent form, you have options. Contact your health plan for help finding an in-network option.

You can find an explanation of what out-of-network laws are currently in place in your state here.

The law may not pre-empt state surprise billing laws that establish a process for determining OON reimbursement for covered items and services for insurers subject to the state’s law.

Insurer and health plans: provisions applicable to insurers and health plans are enforced by the applicable federal agency (the Departments of Health and Human Services, Labor, and the Treasury).

Providers and facilities: provisions applicable to health care providers and facilities are enforced by the Department of Health and Human Services which may impose fines of up to $10,000 per violation.

States: provisions applicable to providers and facilities (including air ambulance) may be enforced by the states.

The No Surprises Act is effective for plan years when they commence on or after January 1, 2022.  Therefore, if a plan renews during 2022, the No Surprises Act will go into effect on the renewal date.

For example, if a plan year commences on December 1, 2022, the No Surprises Act will go into effect on that date.

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