No Surprises Act and Good Faith Estimates
Your rights and protections against surprise medical bills
When you receive emergency care or treatment from an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing, also known as balance billing.
What is balance billing? (sometimes called surprise billing)
When you see a 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— 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.
You are protected from balance billing for:
If you have an emergency medical condition and receive 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 can’t be balance-billed for these emergency services. This includes services you may receive after you’re in stable condition, unless you give written consent and give up your protections not to be balance-billed for these post-stabilization services.
If you receive 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’re never required to give up your protections from balance billing. You also aren’t required to receive care out of network. You can choose a provider or facility in your health plan’s network.
When balance billing isn’t allowed, you also 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 or out-of-network
services toward your deductible and out-of-pocket limit.
Good faith estimate
You have the right to receive a good faith estimate explaining how much your health care will cost. Under the law, health care providers need to give customer-owners who don’t have or are not using certain types of health care an estimate of their bill for health care items and services before those items or services are provided.
- You have the right to receive a good faith estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
- A good faith estimate does not include unknown or unexpected costs that arise during treatment.
- You could be charged more if issues or special circumstances arise. If that occurs and you are billed $400 or more for any provider or facility than the good faith estimate provided, federal law allows you to dispute the bill.
- If you schedule a health care item or service at least three business days in advance, make sure your health care provider or facility gives you a good faith estimate in writing within one business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, make sure you receive a good faith estimate in writing within three business days after scheduling. You can also ask for a good faith estimate before you schedule an item or service. If you request a good faith estimate, you should receive it in writing within three business days after you ask.
If you believe you’ve been wrongly billed, customer-owners can file complaints at firstname.lastname@example.org or (800) INSURAK for enforcement issues related to state regulated plans. For enforcement issues related to federally regulated plans, call (800) 985-3059 or click here.
If you have any questions about your bill, you can contact the clinic in which you received services for more information.