No Surprises Act

Beginning January 1, 2022, patients have a right to an estimate of the cost of services they will receive during a procedure or surgery, called a Good Faith Estimate, and more protection from unexpected, or surprise, bills when they receive care from out-of-network providers at in-network facilities. These protections are part of the Consolidated Appropriations Act of 2021 which includes the No Surprises Act.

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 patients who don’t have certain types of health care coverage or who are not using certain types of health care coverage 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.
  • If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate inwriting within 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the healthcare provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask.
  • If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.
  • Make sure to save a copy or picture of your Good Faith Estimate and the bill.

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, 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.

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.

Emergency services

If you have an emergency medical condition and get 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 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.

You may be entitled to additional protections under Florida law. See below for details.

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 may 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 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 may be entitled to additional protections under Florida law. See below for details.

You are never required to give up your protection from balance billing. You also are not required to get care out-of-network. You can choose a provider or facility in your plan’s network.

When Balance Billing Is not 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 payout-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 services or out-of-network services toward your deductible and out-of-pocket limit.

If you think you’ve been wrongly billed, you may contact the U.S. Department of Health and Human Services’ No Surprises Helpdesk at 1-800-985-3059, which is the entity responsible for enforcing the federal balance or surprise billing protection laws. Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf and follow CMS version 2 guidelines for more information about your rights under federal law.

FLORIDA LAW

If you are covered under certain types of health plans, including health management organizations (HMOs), preferred provider organizations (PPOs), and exclusive provider plans (EPOs), you may be entitled to additional protections against balance billing under Florida law.

Contact the Florida Office of Insurance Regulation at 850.413.3140 or visit the https://www.floir.com/ for more information about your rights under Florida law.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.

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