No Surprises Act and Balance Billing: What You Owe

Balance billing is when a provider bills you for the difference between the provider's charge and the allowed amount. The allowed amount is the price your plan treats as payable for a service. In-network providers usually agree not to bill you that difference. Out-of-network providers have no such agreement.

A surprise bill is the everyday name for an unexpected out-of-network bill. It can happen when you use an in-network hospital but one of the people treating you is not in your network, or when you need emergency care and cannot choose where to go. A federal law called the No Surprises Act, in effect since January 1, 2022, limits these bills.

With most job-based or individual health insurance, the law protects you from unexpected out-of-network bills in three situations. The first is emergency care, including care from out-of-network providers. So yes, these protections apply to emergency room visits.

The second is certain non-emergency care from an out-of-network provider during a visit to an in-network hospital, hospital outpatient department, or ambulatory surgical center (a facility that does same-day surgery). The third is air ambulance services.

For protected emergency care, you can't be charged more than in-network cost sharing. Cost sharing is your share of the cost through a copayment, deductible, or coinsurance. The out-of-network provider cannot balance bill you for the rest.

The non-emergency protection has limits. CMS says it doesn't apply at a doctor's office that isn't a hospital outpatient department, or at an out-of-network facility.

Sometimes. For certain non-emergency care, an out-of-network provider at an in-network facility may ask you to sign a notice and consent form. Signing it means you agree to get care out of network and give up your billing protections. CMS says you will likely pay more than you would in your plan's network.

Signing is your choice. A provider or facility may refuse to give non-emergency care if you decline, so you might need to reschedule with an in-network provider. The form must be given to you separately from other documents.

Some providers can never ask you to sign. Providers can't ask you to give up your protections for emergency care. CMS also says providers can't ask for items and services related to emergency medicine, anesthesiology, pathology, radiology, or neonatology, or for diagnostic services, including radiology and lab work. Assistant surgeons, hospitalists, and intensivists can't ask either, and no provider can ask if no in-network provider at the facility can give you that service.

The federal protections apply to most types of private health insurance. CMS lists several exceptions. Ground ambulance services are generally not covered, so a ground ambulance can still charge out-of-network rates. CMS says some states have their own ground ambulance billing protections.

Vision-only and dental-only plans are generally not covered, although protections may apply if dental or vision benefits are part of a health plan. Covered services under short-term limited-duration plans and health care sharing ministry plans are not subject to the protections. The same goes for fixed indemnity plans, such as hospital indemnity insurance.

Medicare, Medicaid, Indian Health Service, VA health care, and TRICARE already offer some protection from unexpected out-of-network bills.

A good faith estimate is a list of expected charges before you get care. Usually, if you don't have or use health insurance, providers must give you one. You get it when you schedule care at least 3 business days ahead, or when you ask for one. It is not a bill, and each estimate covers only one provider or facility.

Under the rules in effect since 2022, if a provider's or facility's final bill is at least $400 more than its estimate, you may be able to dispute it. You have to start within 120 days (about 4 months) of getting your initial bill, and CMS charges a $25 non-refundable fee to file. An independent third party reviews the bill and decides an appropriate payment. You need a written estimate to use this process, so ask for it in writing and keep a copy.

Do not ignore a bill you think is wrong, and do not pay it until you understand it. CMS runs a No Surprises Help Desk that can help you work out whether the law applies to you. It can't give legal advice, medical advice, or financial help, but it can point you to other agencies. A Prime Health Consultants advisor can explain how the process works and guide you through the steps. Keep in mind that only your plan or the provider can change the bill itself.

These are federal rules for most job-based plans and individual health insurance. Short-term health plans, fixed indemnity plans, health care sharing ministries, and some government or church plans can work differently, and CMS says the federal law supplements state surprise billing laws. Your plan documents control.