Your Right and Protections Against Surprise Medical Bills
PLEASE NOTE: The No Surprises Act is a new federal law enacted by Congress in December 2020. As noted in this interactive, some states have laws that have protected some state residents from surprise bills. The No Surprises Act will now protect all consumers with private health insurance— including the more than 163 million people with job-based coverage — from out-of-network surprise bills in certain situations. These new protections go into effect for health plan years that begin on or after January 1, 2022. Key rules implementing the new federal law were issued in July and September 2021.
“Balance bills” primarily occur in two circumstances: 1) when an enrollee receives emergency care either at an out-of-network facility or from an out-of-network provider, or 2) when an enrollee receives elective nonemergency care at an in-network facility but is inadvertently treated by an out-of-network health care provider. Since the insurer does not have a contract with the out-of-network facility or provider, it may decide not to pay the entirety of the bill. In that case, the out-of-network facility or provider may then bill the enrollee for the balance of the bill. While 33 states have enacted laws to protect enrollees from balance billing, the scope of these protections varies as shown in the map below. Congress enacted the No Surprises Act in 2020 to protect most people who are not currently protected under this patchwork of state laws. This federal law goes into effect on January 1, 2022.
Monday – Friday
7:00 am – 2:30 pm
Partial Balance Billing Protections
- State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing*
- Above protection applies:
- To HMO and PPO enrollees**
- For (1) emergency services provided by out-of-network professionals at in-network facilities and (2) non-emergency services provided by out-of-network professionals at in-network facilities
- Provided by all or most classes of health care professionals
- State provides a dispute resolution process for claims over $1000, which must be initiated by the enrollee***
- Protections do not apply to:
- ground ambulance services
- services at out-of-network facilities
- enrollees who consent to non-emergency out-of-network services****
- enrollees of self-funded plans
* In Arizona, providers are not prohibited from balance billing PPO members. But in cases where a dispute-resolution process is used, a balance bill cannot be submitted after the arbitrator has made a decision.
** Protections apply only to health plans that cover out-of-network care and according to state interpretation, the Arizona protection covers enrollees in HMOs.
*** State requires the arbitrator to allow parties to provide the following information to inform the decision: (1) the average contracted amount the health insurer pays for the services at issue in the county where the services were performed; (2) the average amount the provider has contracted to accept for the services at issue in the county where the services were performed; (3) Medicare and Medicaid reimbursement rates; and (4) the provider’s direct pay rate for the services at issue, if any.
**** The provider must give the enrollee a written dated disclosure “a reasonable amount of time” before the enrollee receives services. The disclosure has to include:
– a notice with the name of provider informing the enrollee of the provider’s out-of-network status,
– estimated total cost, and
– a notice that the enrollee is not required to sign the disclosure to obtain care, but if they do sign it, they waive rights to dispute resolution.
Enrollees are not protected with respect to non-emergency services if the provider follows these rules for disclosure but if the enrollee declines to agree to the disclosure, the protections still apply.