The No Surprises Act, which took effect January 1, 2022, provides federal protections against "surprise medical billing" for patients receiving emergency care or services from out-of-network providers at in-network facilities. Under the law, patients are only responsible for their in-network cost-sharing amounts, such as copayments or deductibles, preventing providers from billing patients for the balance of the total cost. According to the Centers for Medicare & Medicaid Services (CMS), these protections apply to most private health plans, including employer-sponsored coverage and plans purchased through the Health Insurance Marketplace.
Scope of Federal Billing Protections
The legislation specifically targets instances where a patient cannot choose their provider, such as during an emergency or when undergoing a procedure at an in-network hospital where an out-of-network clinician, such as an anesthesiologist or radiologist, is involved. The Kaiser Family Foundation (KFF) notes that the law effectively shifts the dispute resolution process from the patient to the insurer and the healthcare provider. If a provider and an insurer cannot agree on the payment amount for services rendered, they must enter an Independent Dispute Resolution (IDR) process rather than involving the patient in the financial disagreement.
Understanding Out-of-Network Costs
While federal law protects patients from balance billing, the actual cost of childbirth or surgical procedures remains highly variable depending on the patient’s specific health insurance plan and the facility’s status. Data from the Health Care Cost Institute indicates that median costs for childbirth delivery vary significantly by state due to differences in labor market costs, facility fees, and state-level regulatory environments.
Even with the No Surprises Act, patients should verify if their hospital and attending physician are in-network before a scheduled procedure. If a patient chooses to use an out-of-network provider for non-emergency care, they may be asked to sign a "Notice and Consent" form. By signing this document, the patient acknowledges they are waiving their No Surprises Act protections and agrees to pay higher out-of-network rates. The Department of Health and Human Services (HHS) emphasizes that providers cannot force patients to sign these waivers for emergency services or for ancillary services like pathology or radiology at an in-network facility.
How to Dispute a Surprise Bill
If a patient receives a bill that violates the No Surprises Act, they have recourse through federal and state channels. The Consumer Financial Protection Bureau (CFPB) advises patients to:
- Review the Explanation of Benefits (EOB): Check the document sent by the insurance company to confirm the amount billed matches the in-network cost-sharing requirements.
- Contact the Provider: Inform the billing office that the charge may violate the No Surprises Act.
- File a Complaint: If the issue remains unresolved, patients can submit a complaint through the CMS No Surprises Help Desk or their state’s insurance department.
Frequently Asked Questions
Does the No Surprises Act apply to ground ambulance services?
As of 2024, the federal law does not include ground ambulance services in its surprise billing protections, though some states have implemented their own legislation to cap these costs.
Can I still be balance billed if I sign a consent form?
Yes. If you sign a valid "Notice and Consent" form for non-emergency services, you are agreeing to pay the out-of-network rates, and the federal protections against balance billing do not apply.
Does this law cover public insurance like Medicare or Medicaid?
No. The No Surprises Act specifically protects individuals with private or employer-sponsored health insurance. Medicare and Medicaid already have their own federal regulations prohibiting providers from balance billing patients.