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

Connecticut passed its own law in 2015 to address balance billing. The law applies to health plans regulated by Connecticut's Department of Insurance and has similar protections to those provided under the federal No Surprises Act. For more information, please see Conn. Gen. Stat. §§ 38a-477aa and 20-7f.

 

The Connecticut Department of Insurance
https://portal.ct.gov/CID/General-Consumer-Information/No-Surprises-Act 

Consumer Helpline: (800) 203-3447 or (860) 297-3900

The State of Connecticut Office of the Healthcare Advocate 
866-466-4446
Healthcare.advocate@ct.gov

If you are in a Health Maintenance Organization (HMO) governed by Maryland law, you may not be balance billed for services covered by your plan. If you are in a PPO or EPO governed by Maryland law, hospital-based or on-call physicians paid directly by your PPO or EPO (assignment of benefits) may not balance bill you for services covered under your plan and can’t ask you to waive your balance billing protections.

 

If you believe you’ve been wrongly billed, you may contact the Health Education and Advocacy Unit (HEAU) of Maryland’s Consumer Protection Division:


Health Education and Advocacy Unit
Office of the Attorney General
200 St. Paul Place, 16th Floor
Baltimore, Maryland 21202
Phone: 410-528-1840 or toll-free -877-261-8807
En espanol: 410-576-6571
Fax: 410-576-6571
Website: https://www.marylandattorneygeneral.gov/Pages/CPD/HEAU

 

If you believe your health plan processed your claim incorrectly, you may contact the Maryland Insurance Administration:


Maryland Insurance Administration
Life and Health Complaints Unit
200 St. Paul Place, Suite 2700
Baltimore, Maryland 21202
Phone 410-468-2000 or toll free 1-800-492-6115
Fax: 410-468-2260
Website: https://insurance.maryland.gov

New Jersey law prohibits out-of-network providers and health care facilities in New Jersey from balance billing patients in excess of the patient’s deductible, copayment, or coinsurance amount applicable to in-network services for (i) emergency or urgent medically necessary services, and (ii) inadvertent out-of-network services. New Jersey law defines “inadvertent out-of-network services” as health care services (1) covered under a managed care health benefits plan that provides a network; and (2) provided by an out-of-network provider at an in-network health care facility when in-network services are unavailable at that facility. This protection applies to all carriers operating in New Jersey with regards to health benefits plans issued in New Jersey, including self-funded plans that opt-in.


Additionally, Nevada law requires that the patient pay only their in-network cost-sharing amounts. This law does not apply to: (1) any patient who has coverage through an out of state insurance policy; (2) critical access hospitals or any medically necessary emergency services provided at such a hospital and (3) any out-of-network health care services provided 24 hours after notification that a patient has been stabilized.

 

New Jersey Department of Banking and Insurance 
609-292-7272 https://www.state.nj.us/dobi/division_consumers/insurance/outofnetwork.html

West Virginia requires insurers to provide coverage for emergency medical services--including prehospital services--to the extent necessary to screen and stabilize an emergency medical condition without requiring prior authorization for the screening services or stabilization of the emergency medical condition. Such coverage of emergency services is subject to coinsurance, copayments, and deductibles applicable under the health benefit plan. W. Va. Code Section 33-25A-8d(b)(3).

 

If you believe you’ve been wrongly billed, you may contact the West Virginia Offices of the Insurance Commissioner at https://www.wvinsurance.gov/Consumer_Services or by phone at 304-558-3386 or Tollfree in WV: 1-888-TRY-WVIC.
Visit https://www.wvinsurance.gov/HealthPolicy for more information about your rights under West Virginia law.

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:

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