Title 45, section 149.610 of the Code of Federal Regulations

New federal legislation protects insured Americans from surprise medical bills and remove consumers from payment disputes between a provider or health care facility and their health plan. WHAT DOES THE NO SURPRISES ACT DO?

The No Surprises Act provides federal protections against surprise billing by limiting out-of-network cost sharing and prohibiting “balance billing”.

WHO IS PROTECTED BY THE NO SURPRISES ACT?

The new protections apply to persons with employer provided insurance coverage and individual health insurance plans. Some of these changes will also apply to uninsured or self-pay individuals.

If you receive medical insurance coverage through Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE. These new rules don’t apply to these programs. You are already protected from surprise medical billing by previously existing legislation.

WHAT IS A SURPRISE MEDICAL BILL?

Most health insurance plans have a network of health care providers and facilities that allow their customers to access healthcare and receive the full amount of coverage available under the insurance plan.

A medical professional or healthcare that is not within the insurance plan’s network of providers is considered an “out of network” medical professional or facility.

In the past, receiving healthcare from an out-of-network provider or facility meant not only did you pay a higher copay for the out-of-network healthcare, it also meant the out-of-network provider or facility could bill you for the difference between what they charged and what your insurance covered.

WHAT IS BALANCE BILLING?

Balance billing is the term used to describe the practice of out-of-network providers billing patients for the difference between: (1) the provider's billed charges, and (2) the amount collected from the plan or issuer plus the amount collected from the patient in the form of cost sharing (such as a copayment, coinsurance, or amounts paid toward a deductible).

Because this type of bill was usually for services already considered paid for by the patient AND frequently arrived a considerable amount of time after the medical services were received, it was commonly referred to as a surprise medical bill.

HOW DOES THE NO SURPRISES ACT AFFECT MY CO-PAYS?

• You cannot be charged a higher copay for out-of-network emergency services. You can only be charged health insurance deductibles and copayments for emergency services from the point of initial evaluation until you are medically stable.
• You cannot be charged a higher copay for some out-of-network nonemergency services.
• You cannot be charged an out-of-network charge or receive a balance bill from out-of-network providers at in-network facilities, unless you consent to the same.
• If a provider seeks to have a patient waive the No Surprises Act’s protections, the provider has to give the patient a detailed written consent form at least 72 hours prior to a scheduled appointment, or 3 hours before a same-day appointment.
• Any amount you pay for emergency services or out-of-network services must count toward your deductible and out-of-pocket limit.

WHAT PROTECTIONS DOES THE NO SURPRISES ACT PROVIDE FOR EMERGENCY SERVICES?

• You can no longer receive surprise bills for emergency services, even if the hospital and/or medical providers were not in your insurance plan’s network.
• Health plans can’t deny emergency services coverage based on post-care review if there was a delay between when symptoms began or when the person sought care or based on how long the person had symptoms.

WHAT IF MY DOCTOR OR MEDICAL FACILITY’S NETWORK STATUS CHANGES WHILE I’M RECEIVING TREATMENT?

The No Surprises Act created greater protections for a patient receiving ongoing treatment from a medical provider or facility that terminates their contract with the patient’s insurance provider.

If a medical professional or facility ceases to be an in-network provider because of a termination of a contract with your insurance provider, the No Surprises Act may apply to assure continuity of care for an individual who who meets certain conditions. Acute illness with need for specialized medical treatment to avoid the reasonable possibility of death or permanent harm. Chronic illness with a life-threatening, potentially disabling, or congenital condition requiring specialized medical care over a prolonged period of time.

For the individual who meets these conditions, the insurance plan must:

1. Notify the patient of termination of the contract AND the patient’s right to continue transitional care at the facility.
2. Provide the patient with the ability to notify the insurance provider for the need of transitional care
3. and Allow the patient to receive continuing care at the facility with the same benefits, terms and conditions as before the contract was terminated.

FOR THE UNINSURED or SELF PAYING PATIENT

If you do not have insurance coverage, the new rules require that you get a “good faith estimate” of how much your medical care will cost before you receive it.

These rules also apply to persons with insurance, who elect to go “out-of-pocket” for a medical procedure - e.g. a procedure not covered by the patient’s existing medical insurance.

If you are charged more than 400 dollars above the amount listed on your good faith estimate, you have 120 days to dispute the bill. A process called “Federal Independent Dispute Resolution” will commence. During this time an independent third party reviews the facts and determines the appropriate amount owed. Throughout the dispute process, the medical provider cannot turn the bill over to collections, threaten late fees, or threaten retaliatory action.

EXCEPTIONS TO THE PROTECTION CREATED BY THE NO SURPRISES ACT

1. If you have a dental-only or vision-only plan, these protections will not apply. If dental or vision services are part of your health plan, these protections will apply.
2. Balance billing protections do not apply to most ground ambulance services.

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