No Surprises Act
No Surprises Act: Effective January 1, 2022, the No Surprises Act, which Congress passed as part of the Consolidated Appropriations Act of 2021, is designed to protect patients from surprise bills for emergency services at out-of-network facilities or for out-of-network providers at in-network facilities, holding them liable only for in-network cost-sharing amounts. The No Surprises Act also enables uninsured patients to receive a good faith estimate of the cost of care.
Balance Billing: When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network. Out-of-network describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called balance billing. This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit. Surprise billing is an unexpected balance bill. This can happen when you can’t control who is involved in your care, such as when you have an emergency or if you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
Emergency Services: If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You cannot be balance billed for those emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections to not be balanced billed for these post-stabilization services. Additionally, Texas law protects patients from surprise medical bills in emergencies and when a patient receives covered medical services from an out-of-network provider at in-network facilities. This law applies to state-regulated insurance plans, including the state employee or the teacher retirement systems. However, this law does not apply to nonemergency healthcare or medical services when a patient elects in advance and in writing to receive those services from an out-of-network provider and when the out-of-network provider provides the patient with a written disclosure.
Certain services at an in-network hospital or ambulatory surgical center: When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers cannot balance bill you and may not ask you to give up your protections not to be balance billed. If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections. You are never required to give up your protections from balance billing, and you're also not required to get out-of-network care. You can always choose a provider or facility in your insurance plan's network.
When Balance Billing is not Allowed (IE, Emergency Medical Services) You Have the Following Protections:
You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
Your health plan generally must:
Cover emergency services without requiring you to get approval for services in advance (prior authorization).
Cover emergency services by out-of-network providers.
Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact:
The U.S. Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (1-800-633-4227) or visit https://www.cms.gov/nosurprises for more information about your rights under federal law.
Your health plan to ask them why you got the bill and if it’s correct. If it was an emergency, ask your health plan if they processed your claim as an emergency.
The Texas Department of Insurance Consumer Help Line at 800-252-3439 or visit Texas Department of Insurance, “How to Get Help With a Surprise Medical Bill”
Good Faith Estimates: Under the law, healthcare providers are required to give patients who don’t have insurance or who are not using insurance a Good Faith Estimate explaining how much it is expected that the health care and/or medical treatment, items and services are expected to cost. Specifically, clients'/patients' rights are as followed:
Clients/patients have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs including medical tests, prescription drugs, equipment and hospital fees.
Upon request, healthcare providers are required to provide clients/patients a Good Faith Estimate in writing at least one business day before the provision of the medical service or item. Clients/patients can also ask their healthcare provider for a Good Faith Estimate before they schedule an item or service.
If clients/patients receive a bill that is at least $400 more than their Good Faith Estimate, they can dispute the bill.
Jody L. Miller, LPC is happy to provide Good Faith Estimates to all of her clients and discuss the specifics of the law and answer any questions.