New protections to help you avoid an unpleasant surprise … bill

Editor's note: This blog post contains a number of insurance-related terms that may not be familiar to everyone. To help you understand the protections this new bill provides, we have included a glossary at the end of the post to explain what those terms mean.

On Jan. 2, 2022, the No Surprises Act went into effect, providing health care consumers with several protections from "surprise medical bills." The bill was passed by Congress in December 2020.

According to the Centers for Medicaid & Medicare (CMS), the No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers. People with Medicare and Medicaid are already protected against surprise medical bills.

A surprise medical bill is exactly what it sounds like: a bill related to your health care expenses that you were not expecting. These bills come when a medical expense is not covered by coinsurance, copays or premiums. The bills are usually a surprise because they often arrive after you have gone to an in-network facility and expect all health care providers to be contracted with your insurance company.

You might be wondering, "If I see an in-network provider or go to an in-network facility, how could I end up with bill my insurance will not cover?" The surprise bills usually come when the facility and most of its physicians — but not all — are contracted with the insurance company. The most common example of this situation is in emergency rooms. An emergency room doctor will be contracted with the hospital, but not with the insurance company — and the person needing emergency care does not have the opportunity to ask if the person caring for them is in network. For example, if you need to have an emergency surgery, you will not have the chance to ask the anesthesiologist or the surgeon if they are in network for your insurer.

To protect people from these bills, which can be astronomical and put you in medical debt, this legislation was passed to provide people with a way to fight surprise bills.

As CMS explains, the new rules will:

• Ban surprise bills for most emergency services, even if you get them out-of-network and without approval beforehand (prior authorization).
• Ban out-of-network cost-sharing (like out-of-network coinsurance or copayments) for most emergency and some non-emergency services. You can't be charged more than in-network cost-sharing for these services.
• Ban out-of-network charges and balance bills for certain additional services (like anesthesiology or radiology) furnished by out-of-network providers as part of a patient's visit to an in-network facility.
• Require that health care providers and facilities give you an easy-to-understand notice explaining the applicable billing protections, who to contact if you have concerns that a provider or facility has violated the protections, and that patient consent is required to waive billing protections (i.e., you must receive notice of and consent to being balance billed by an out-of-network provider). You do not have to sign that document.

If you are not insured or are choosing to not use your health insurance, you can ask your provider for a good faith estimate. If you receive a bill that is $400 or more above the amount the provider estimated for you, you can file a complaint with the provider.

If you do receive a surprise bill and are eligible for these protections, you can file a complaint on the Centers for Medicare & Medicaid website.

Glossary

Annual out-of-pocket maximum: The total amount of money that you must pay for health care services before insurance will provide full coverage. This does not include your premium (see below). Once you hit your annual out-of-pocket maximum, all services should be provided without any cost-sharing.

Coinsurance: The amount that you pay when you have a health care service provided. The amount is based on a percentage of the cost, and the percentage is outlined in your health insurance policy.

Copay: A predetermined amount that you pay when you have a health care service provided. It is a flat rate (not a percentage), and the amount is outlined in your health insurance policy.

Cost-sharing: The amount you are responsible to pay in addition to your premium. Cost-sharing can be coinsurance or copays. It can also include your deductible and costs that lead to your out-of-pocket maximum.

Deductible: The amount you must pay in addition to your premium before insurance coverage or different coinsurance or copays start. Please be aware that because of the Affordable Care Act, most preventative services, such as your yearly wellness physical, well woman examinations, mammograms or cancer screenings, must be provided for free.

In-network: Health care providers and facilities who have contracted with your insurance company. They have agreed to be paid by your insurance company and will accept your copay or coinsurance, if necessary, as part of the payment.

Out-of-network: Health care providers or facilities who have not contracted with your insurance company. You will be expected to pay all or part of the bill, depending on your insurance company's policies. If you have health insurance and decided to go to an out-of-network provider, it is very important that you find out how much the service will cost. Also, some health insurance companies do cover some services from out-of-network providers, but will only pay them what they would have paid them if they were in network. The No Surprises Act provides protections in emergency cases or when you had every reason to believe your provider was in network. It is important to confirm your health care provider is in network or confirm the amount that you will be expected to pay if you opt to go to an out-of-network provider.

Premium: The amount you pay usually monthly or quarterly for your health insurance plan.