Overview
A surprise medical bill is an unexpected cost you get when you receive care from a doctor or hospital that is not part of your health insurance plan. This is often called a "balance bill." A balance bill happens when the provider charges you the difference between what they charge and what your insurance pays.
Important Note: If you choose to see a provider that is out of your insurance network on purpose, it is not a surprise medical bill.
How the No Surprises Act helps?
The No Surprises Act helps you in two main ways:
- Emergency Services: If you get emergency care at a hospital or from an ambulance, your insurance will pay for it right away, without needing approval. This works whether the provider is in your plan's network or not. (ground ambulance services are not covered.)
- Non-Emergency Services: If you go to a doctor who is in your network but get care from a doctor who is out of your network, your insurance will still pay for it like it would for an in-network provider.
In both cases, this law protects you from paying more than you would if all providers were in your network. The No Surprises Act also requires healthcare providers and facilities to give patients clear information about their billing rules, including what is covered and what is not.
What to Do If You Get a Surprise Bill
If you think you received a surprise bill and need help, fill out the No Surprises Bill Review Request Form. A special team will help you determine if you should pay the bill and how to resolve the issue. You should not pay more than you would have if the provider was in your network. It is the provider's job to know if a service is protected by the Act.
Check the 'Resources' section for more information, including answers to common questions and the No Surprises Bill Review Request Form.
If you have questions about your insurance or need to file a complaint with your insurance company, agent, broker, or public adjuster, you can contact our Consumer Services Bureau for help.
Frequently Asked Questions (FAQs)
- Emergency air ambulance services
- Emergency facility/provider services
- Non-emergency services in connection to a visit to a facility
- Emergency room providers
- Anesthesiologists
- Pathologists
- Radiologists
- Neonatologists
- Assistant surgeons
- Hospitalists
- Intensivists
- Diagnostic services like radiology and laboratory *Advanced diagnostic laboratory tests are not included
- Other specialty items or services as identified by HHS
- Any service provided by an out-of-network provider if no in-network provider was available at the facility
- Urgent services that arise during a service for which Notice and Consent was provided
Surprise billing protections apply if you get your coverage through:
- Your employer (including a federal, state, or local government)
- Our state-based Marketplace, Pennie
- Directly through an individual market health insurance company.
*The Act does not apply to people with coverage through programs such as Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE as they have protections under other laws and do not allow for balance billing.
Participants in the following plans do not have the balance billing protections:
- Indemnity or excepted benefit plan enrollees
- A plan that is not an "individual market" coverage plan
- A plan does not typically have a network
- Short-term limited duration plan enrollees
- Healthcare sharing ministry or Amish participants
- Individuals with no health care coverage at all
Yes, an emergency is when someone thinks they need quick help because they could get really hurt or their body might not work right.
No. An emergency service may not be subject to prior authorization. There is no prior authorization allowed.
No. The service cannot be re-coded to a non-emergency based on the diagnosis code.
Yes. Providers, like hospitals and labs, must show important information if they give services at their facility or during your visit. They need to share this information before they ask for payment or send a bill to your insurance plan.
You shouldn’t sign the Notice and Consent unless you are sure you want a specific provider to do the medical service. Note: If the provider is one who can never send a surprise bill, you should file a complaint right away.
No, a Notice and Consent must be a separate document. It may not be included in another document or attached to another document.
The Notice and Consent must explain:
- That the Provider does not participate with the Patient's healthcare coverage plan (the Plan).
- The good faith estimated amount the Provider may charge the Patient for all services that would reasonably be included.
- Notice that the service might need to be authorized or otherwise approved by the Plan.
- Clearly state that signing the Notice is Optional; a Patient does not have to consent.
- Clearly state that the Patient may get the service from an available in-network Provider.
A Notice and Consent must be given at least 72 hours (3 days) before a service is provided. If the service is scheduled within 3 days, the Notice must be given at least 3 hours before the service.
You should not sign anything they do not understand. The law and regulations say that the Notice be clear and understandable. The law also says that you may not be pressured into signing the Notice.
Yes. This can be done before the service is provided.