No Surprises Act

Learn about new rights and protections to end surprise bills, better understand costs before getting health care, and minimize payment disagreements.

 

Your Rights and Protections Against Surprise Medical Bills

 

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

 

What is “balance billing” (sometimes called “surprise billing”)?
 

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional 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” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is calledbalance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or 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—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

 

You’re protected from balance billing for:
 

Emergency services If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

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 can 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 can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other types of 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’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.

 

State Specific Rules

Indiana law protects patients from balance billing for non-emergency services provided by out-of-network providers at in-network facilities. This protection does not apply if a patient has received advanced notice from an out-of-network provider and consents to the pricing of the healthcare services. This protection limits the financial liability of patients to the rate paid to the out-of-network provider by the covered individual’s network plan plus any in-network cost-sharing amounts. This prohibition applies to all patients with coverage through a network plan.
Indiana also protects patients with coverage through an HMO from balance billing for: emergency services received from an out-of-network provider or at an out-of-network facility and any covered services performed by an out-of-network provider when the covered service is not available through in-network providers, provided the patient has a referral. Indiana law requires the patient to pay only in-network expenses.

 

Indiana Department of Insurance
800-622-4461 or 317-232-2395
consumerservices@idoi.in.gov
Websites: https://content.govdelivery.com/accounts/INDOI/bulletins/29ac870

https://www.in.gov/idoi/consumer-services/

Michigan law protects patients from balance billing and requires that the patient pay only their in-network cost sharing amounts for: (i) covered emergency services provided by an out-of-network provider at an in-network facility or out-of-network facility; (ii) covered nonemergency services provided by an out-of-network provider at an in-network facility if the patient does not have the ability or opportunity to choose an in-network provider; and (iii) any healthcare services provided at an in-network facility from an out-of-network provider within 72 hours of a patient receiving services from that facility’s emergency room.

Additionally, Michigan law states if the patient consents to receive non-emergency care from an out-of-network provider, the balance billing prohibition does not apply. These protections apply to any patient covered by a Michigan health benefit plan and a self-funded plan established or maintained by the state or local unit of government for its employees.

 

Michigan Department of Insurance and Financial Services 
877-999-6442

https://www.michigan.gov/difs/0,5269,7-303--561696--,00.html 

Ohio law protects patients from balance billing and requires patients to pay their in-network cost sharing amounts for: (i) emergency services provided by an out-of-network provider or provided at an out-of-network emergency facility; and (ii) medical services provided by an out-of-network provider at an in-network facility if a patient did not have the ability to request an in-network provider. For services provided to a covered patient by an out-of-network provider at an in-network facility, a patient cannot be balance billed unless the patient is informed, provided with a good faith estimate of the cost of the healthcare services, and consents.
Additionally, the Ohio law applies to patients covered under state-regulated insurance plans and insurance plans subject to the jurisdiction of the superintendent of insurance.

 

Ohio Department of Insurance 
800-686-1526

https://insurance.ohio.gov/strategic-initiatives/surprise-billing/resources/01-surprise-billing-toolkit

When balance billing isn’t allowed, you also have these protections:

 

  • You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
  • Generally, your health plan must:
  • Cover emergency services without requiring you to get approval for services in advance (also known as “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 in-network deductible and out-of-pocket limit.
If you think you’ve been wrongly billed, contact 1-800-985-3059. Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost

 

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

  • You 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 like medical tests, prescription drugs, equipment, and hospital fees.
  • Make sure your health care provider gives you a Good Faith Estimate writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
  • If you receive a bill that is at least $400 more than your Good FaithEstimate, you can dispute the bill.
  • Make sure to save a copy or picture of your Good Faith Estimate.
 
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.

For Your Good Faith Estimate, Contact:

Contact Us


Email:
billing@pathlabs.org

Phone: 419.255.4603 or 866.755.8855