No Surprises Act: What You Need to Know

What is the No Surprises Act?

The No Surprises Act (the “Act”) took effect on January 1, 2022. The Act restricts surprise and excessive out-of-pocket balance bills for consumers.  It also ensures coverage of emergency services without prior authorization and regardless of network status.

Does the No Surprises Act prevent balance bills?

No. The law only bans “surprise” balance bills. A “balance bill” is a medical bill from a healthcare provider billing a patient for the difference between the total cost of services being charged and the amount the patient’s health plan pays. A surprise bill is when a patient is not likely to know or anticipate a balance bill from a healthcare provider for the following services:

• Out-of-network emergency care
• Emergency care by out-of-network providers at an in-network facility
• Non-emergency treatment by out-of-network providers at an in-network facility
• Out-of-network air ambulance services (ground ambulance services not included)

If there is a dispute related to payment, the dispute must be resolved by the patient’s health plan and the provider.

May a patient still receive a balance bill?

Yes. A provider may still send a balance bill to a patient by mistake or if they dispute whether the service is covered under the Act.  A patient may also be balance billed if the patient provides consent to the provider to be balance billed in connection with the service. Balance billing may, therefore, occur if the patient consents, even though a service is covered under the Act.

What does “notice and consent” mean?

To legally send a patient a balance bill, an out-of-network healthcare provider must:

• Provide notice to the patient that they are receiving care from an out-of-network provider and that the patient may receive a balance bill
• Require the patient to sign an informed consent waiver acknowledging the patient may receive a balance bill at least 72 hours before the scheduled service and
• Provide the patient a good-faith cost estimate and identify available in-network options for obtaining the service

What to do if you receive a balance bill for emergency or non-emergency care?

If you receive a balance bill for emergency care, contact your health plan directly to have them resolve the payment dispute.

If you receive a balance bill for non-emergency care, contact your health plan directly with a copy of your bill and any intake paperwork received. Intake paperwork should contain the required Notice and Consent form from the healthcare provider. The Intake paperwork will help determine if the healthcare provider may legally send you a balance bill or whether your bill would fall under the protections of the No Surprises Act.

When seeking medical care, you must carefully read everything that you are required to sign in order to take advantage of the protections under the Act, and not consent to being balance billed.

Click here to read more about the No Surprises Act from NPR.