Americans are concerned about unexpected medical bills more than any other expense, according to Kaiser Family Foundation surveys in 2018 and 2020.
Unfortunately, these bills aren’t uncommon: 18% of emergency visits and 16% of hospital stays had at least one out-of-network fee, according to a 2020 Peterson-KFF Health System Tracker study.
The No Surprises Act, which bans most surprise medical bills from January 1, could ease those concerns.
“This law puts an end to the practice of billing patients exorbitantly for unexpected out-of-network care,” Senator Patty Murray, chair of the Senate Health, Education, Labor and Pensions Committee, said in an email.
Here are answers to some common questions about the No Surprises Act and what it might mean for your money.
What is a sudden medical bill?
A medical surprise bill is one you wouldn’t expect from an out-of-network provider. They often appear when you didn’t choose a doctor or didn’t know they weren’t in your network.
“You can’t control where the ambulance takes you for emergency treatment,” says Patricia Kilmar, health care campaigns manager for the US Public Interest Research Group, or PIRG America, a federation of state-based consumer advocacy organizations. “You can’t control who’s anesthetizing you or doing your lab work once you’re in the hospital – in the hospital within your network.”
Insurance companies often require co-pays, co-insurance, or higher deductibles for out-of-network care. Your provider can also charge you for what’s left after your insurance company pays its share of the bill, a practice called “balance billing.”
What does Act No Surprises?
The No Surprises Act prohibits budget bills for emergency services and some non-emergency services.
First, your insurance must cover emergency services as being in-network without prior authorization. Balance billing is not allowed for emergency care, even in out-of-network hospitals or emergency departments.
If you go to an in-network hospital or ambulatory surgical center for non-emergency care, balance bills will not be allowed for any of these additional services:
- Anesthesiology, pathology, radiology or neonatology.
- Care from assistant surgeons, hospital doctors, or intensive care specialists.
- Diagnostics such as radiology or laboratory services.
- Any other item or service from a provider outside the network, if the network provider is not available.
You cannot waive or forfeit your protection against credit bills for emergency services or additional services at facilities within the network. All you have to do is pay the in-network participation amount, the coinsurance or the deductible.
Approval of off-network billing
You may want to seek care from a specific provider such as an expert in specialty surgery, even if they are out of network. An out-of-network provider at an in-network facility cannot bill you a credit only if all of these things are true:
- The provider is not in the list of additional services above.
- They give you an explanation in plain language of your rights.
- You give written consent to give up your protection against balance bills.
If you don’t give your consent, they can’t bill you as being out of network, but they can refuse your transaction.
“I really encourage patients to think very carefully before giving up their rights and signing this form,” Kilmar says. “They have every right to ask for a provider in the network. The hospital should provide them with one… If they want to stay in the network, they shouldn’t sign the form.”
Disagreements over what you owe
If you are paying for the services yourself, you have the right to obtain a good faith cost estimate from the provider. If your provider pays you $400 or more above this estimate, you can challenge the bill.
If you use insurance, your insurance company can tell you what’s covered and estimate the costs you’re paying out of pocket. If your insurance company rejects a claim because it says some services are not covered, you can contest that decision.
Kelmar and US PIRG have worked with the federal government to create what they call a “one-stop shop to go to with any questions or complaints.” You may call at 800-985-3059 or visit CMS.gov for disputes or any other No Surprises Act issues.
Arbitration between service providers and insurance companies
The No Surprises Act provides insurance companies and healthcare providers with a fair process for resolving it [out-of-network] “It bills at no additional cost to patients,” said Murray, a Democrat from Washington state.
You do not need to get involved in negotiations or disagreements between your service providers and your insurance company. If they disagree about a payment, they must either resolve it themselves or use a new arbitration process.
While patients aren’t directly involved, “we really care about how well the judging works,” says Kilmar. “It was very important to us to have a reasonable payment made to the provider that wouldn’t increase long-term costs for our health plans – and which we’ll see carry over to us in premiums in the future.”
What is not covered by the No Surprises Act?
The No Surprises Act prohibits all surprises and off-network bills. Here are two important exceptions:
- AmbulancesAir ambulances are covered by law, but not regular ground ambulances.
- Services: The law applies to care provided in hospitals, emergency departments, and ambulatory surgical centers. Other facilities such as clinics and urgent care centers are not included but can be added later.
These protections do not apply to people covered by Medicare, Medicaid, TRICARE, Veterans Affairs or Indian Health Services because they are already protected from sudden medical bills.
Will the No Surprises Act affect health care costs?
“I’ve worked very hard to make sure that the bill we passed would end surprise bills in a fair way that doesn’t raise costs for patients in other ways like higher insurance premiums,” Murray said. The No Surprises Act could achieve this goal, according to the nonpartisan Congressional Budget Office, or CBO.
Most health insurance premiums can drop by 0.5% to 1%, according to CBO estimates, so both patients and the government will pay a little less to insurance companies.
The article What No Surprises Means to Your Medical Bills Act originally appeared on NerdWallet.