The No Surprises Act Explained: Your Rights Against Unexpected Bills

Imagine receiving emergency care, only to be hit with a massive bill weeks later from a doctor you didn't even know was out-of-network. For millions of Americans, this scenario was a painful reality, contributing to medical debt and financial stress. The good news? A landmark federal law, the No Surprises Act, is designed to protect you from many of these unexpected medical bills.

Passed in December 2020 and effective January 1, 2022, this law is a big improvement for insured individuals facing out-of-network charges for emergency services and certain non-emergency care. It also provides new protections for uninsured patients. If you've ever felt trapped by the complexities of healthcare billing, this guide explains your rights and how to use them.

How to Choose Which Protection Applies to You

Answer these questions in order:

1. Do you have private health insurance (through an employer, the Marketplace, or bought on your own)? If yes, the surprise billing protections can apply. If your only coverage is Medicare, Medicaid, or another federal program, go to step 5.
2. Was it an emergency? Emergency care is protected at in-network and out-of-network facilities. You pay only your in-network cost-sharing.
3. Was it scheduled care at an in-network hospital or surgery center? An out-of-network doctor there cannot balance bill you, unless you validly signed a notice and consent form. You can never waive protections for ancillary services such as anesthesiology or radiology.
4. Was it an air ambulance? Protected. A ground ambulance is not covered by the federal law, but your state may have its own rules.
5. Are you uninsured, or not using insurance? You have the right to a Good Faith Estimate for scheduled care. If a provider bills you at least $400 more than its estimate, you can dispute the bill within 120 days.

Your situation	Protected from surprise bills?	What you owe	Where to go if something is wrong
Private insurance, emergency care	Yes, at any facility	Your in-network cost-sharing	Your insurer, then the No Surprises Help Desk
Private insurance, out-of-network doctor at an in-network hospital or surgery center	Yes, unless you validly waived it (never for ancillary services)	Your in-network cost-sharing	Your insurer, then the No Surprises Help Desk
Private insurance, air ambulance	Yes	Your in-network cost-sharing	Your insurer, then the No Surprises Help Desk
Ground ambulance	No federal protection	Depends on your state	Your state insurance department
Uninsured or self-pay, scheduled care	Good Faith Estimate rights	The estimate; you can dispute if billed $400 or more over it	Federal patient-provider dispute process ($25 fee)
Medicare, Medicaid, CHIP, VA, IHS, TRICARE	These programs have their own balance-billing protections	Set by the program	The program itself

Understanding the Problem: Surprise Medical Bills

Before the No Surprises Act, a common scenario involved patients receiving care at an in-network hospital, only to later discover that a particular doctor involved in their treatment – like an anesthesiologist, radiologist, or assistant surgeon – was not in their insurance network. These out-of-network providers would then "balance bill" the patient for the difference between their full charge and what the insurance company paid, leaving the patient with an unexpected and often exorbitant bill.

A KFF analysis of 2017 claims found that 18 percent of emergency visits and 16 percent of in-network hospital stays for people with large employer coverage had at least one out-of-network charge. Most of the potential surprise charges came from doctors and other professionals, not from the hospital itself.

What is the No Surprises Act?

The No Surprises Act is a federal law designed to protect people covered by group and individual health plans from receiving surprise medical bills for most emergency services, non-emergency services from out-of-network providers at in-network facilities, and air ambulance services.

Simply put, it stops most surprise billing for

1. Emergency services: Whether you go to an in-network or out-of-network emergency room, you cannot be balance billed for out-of-network services. Your cost-sharing is limited to your in-network amount.
2. Non-emergency services at in-network facilities: If you receive scheduled care at an in-network hospital or ambulatory surgical center, but an out-of-network provider (like an anesthesiologist or radiologist) is involved, you cannot be balance billed by that provider. Your cost-sharing is limited to your in-network amount.
3. Air ambulance services: You cannot be balance billed for out-of-network air ambulance services.

It's important to note that the Act generally applies to insured individuals. But it also includes a crucial protection for the uninsured and self-pay patients, which we'll discuss below.

How the No Surprises Act Protects You

The core protection of the No Surprises Act is that for the services it covers, you are only responsible for your in-network cost-sharing amount. This means your copay, deductible, and coinsurance will be based on what you would pay if the provider were in-network, not the often much higher out-of-network rates.

For Insured Patients:

• Emergency Care: If you have an emergency, go to the nearest emergency room. You will not be balance billed by out-of-network providers or facilities. Your insurer must pay for your emergency care, and your cost-sharing is capped at your in-network rate.
• Non-Emergency Care at In-Network Facilities: If you schedule a procedure at an in-network hospital or ambulatory surgical center, and an out-of-network provider provides services there, you are protected. The Act prevents these providers from balance billing you. This often covers services like laboratory tests, radiology, and anesthesiology. Your cost-sharing will be based on your in-network rates.
• No Surprise Ground Ambulance Bills (Yet): While air ambulance services are covered, ground ambulance services are generally not covered by the federal No Surprises Act. Some states have their own protections, so it's essential to check your state's laws.

For Uninsured or Self-Pay Patients: The Good Faith Estimate

Even if you don't have insurance or choose to pay for your healthcare directly, the No Surprises Act offers a significant protection: the "Good Faith Estimate."

What it means for you

• Before Scheduled Services: If you are uninsured or choose not to use your insurance, healthcare providers and facilities must give you a Good Faith Estimate (GFE) of the cost of your medical care before you receive it. This estimate should include all expected charges for primary items and services related to your care, including items and services provided by other providers who are part of your scheduled care (e.g., an anesthesiologist during surgery).
• Timeline: You should receive this estimate within specific timeframes:
  • If you schedule a service at least 3 business days in advance, you should get the GFE within 1 business day.
  • If you schedule a service at least 10 business days in advance, you should get the GFE within 3 business days.
  • If you request an estimate without scheduling, you should get it within 3 business days.
• Dispute Rights: If a provider or facility bills you at least $400 more than its Good Faith Estimate, you have the right to dispute the bill through the federal patient-provider dispute resolution process. You must start within 120 calendar days of the bill. The fee is $25, and if the decision goes your way, the $25 is taken off what you owe. While the dispute is open, the provider cannot send the bill to collections or threaten to.

This provision helps you to understand the potential costs upfront, allowing you to make informed decisions and budget accordingly, rather than facing a surprise bill after treatment.

When Does the Act NOT Apply?

While the No Surprises Act provides broad protections, it's essential to understand its limitations:

• Ground Ambulance Services: As mentioned, ground ambulance services are generally not covered by the federal Act. Check your state's laws for potential protections.
• Non-Emergency Services from Out-of-Network Facilities: If you choose to go to an out-of-network hospital or facility for non-emergency care, the Act typically does not protect you from balance billing by that facility or its providers.
• Planned Out-of-Network Care with Consent: For certain non-emergency services, an out-of-network provider at an in-network facility can still balance bill you if they give you proper notice and you voluntarily sign a consent form agreeing to be billed. If you schedule at least 72 hours ahead, the notice and consent documents must reach you at least 72 hours before care. If you schedule within 72 hours, you must get them the day you schedule, and never later than 3 hours before care. You can still decline. You can never waive your rights for ancillary services (such as emergency medicine, anesthesiology, pathology, radiology, lab work, neonatology, or assistant surgeons), for unforeseen urgent needs that come up during care, or when no in-network provider is available at the facility.
• Medicare, Medicaid, and other federal programs: The surprise billing protections do not apply to people whose coverage is only through Medicare (including Medicare Advantage), Medicaid (including Medicaid managed care), CHIP, the Indian Health Service, VA health care, or TRICARE. These programs already have their own protections against balance billing.
• Some other coverage types: The protections also do not apply to short-term, limited-duration insurance, health care sharing ministries, or retiree-only plans.

Your Role: What to Do If You Get a Surprise Bill

Even with the No Surprises Act, errors can happen. If you believe you've received a bill that violates your protections, here's what you can do:

1. Review Your Explanation of Benefits (EOB): Your EOB from your insurance company should clearly state what was paid and what you owe. Look for codes or language indicating out-of-network charges for covered services.
2. Contact Your Provider and Insurer: Call the provider or facility that sent the bill and explain that you believe the bill violates the No Surprises Act. Also, contact your insurance company and inform them of the situation. They should be able to help clarify or correct the billing.
3. Gather Documentation: Keep records of all bills, EOBs, communications (dates, times, names of people you spoke with), and any consent forms you may have signed.
4. File a Complaint: If the provider or insurer doesn't resolve the issue, you can file a complaint with the federal government:
   • Call the No Surprises Help Desk: 1-800-985-3059 (7 days a week, with help in many languages).
   • Visit the CMS Medical Bill Rights Website: https://www.cms.gov/medical-bill-rights
   • You can also contact your state's Department of Insurance or Attorney General's office, as they may have additional resources or state-specific protections.

Remember, you have rights. Don't pay a bill you believe is a surprise bill until you've investigated and understand your obligations.

Actionable Next Steps to Protect Yourself

1. Before Scheduled Care (if insured): Always confirm with your insurance company that all providers and the facility involved in your care are in-network. This includes surgeons, anesthesiologists, radiologists, and any other specialists. While the Act protects you from many surprise bills, proactively choosing in-network care is always the safest option.
2. Request a Good Faith Estimate (if uninsured/self-pay): For any scheduled non-emergency service, demand a Good Faith Estimate from your provider. This is your right under the No Surprises Act. Compare estimates from different providers if possible to find the most affordable option. Prices can vary significantly by location and provider for the same service.
3. Understand Your EOB: Learn to read your Explanation of Benefits. It's your official record of what your insurance paid and what you owe. If anything looks incorrect or unexpected, question it immediately.
4. Know Your State Laws: While the No Surprises Act is federal, many states have their own laws offering additional protections against surprise billing. Research your state's specific regulations.
5. Don't Hesitate to Dispute: If you receive a bill that seems to violate the No Surprises Act, do not ignore it. Follow the steps above to dispute it. Your timely action can save you from significant financial burden.

How FairVisitHealth Helps

FairVisitHealth.com helps self-pay patients by providing transparent, upfront pricing information for various medical procedures, helping you compare costs and avoid unexpected bills before you even receive care. Our platform aims to give you the clarity you need to make informed healthcare decisions.

Frequently Asked Questions About the No Surprises Act

Q: What is balance billing?

A: Balance billing occurs when an out-of-network provider or facility bills you for the difference between what your insurer paid and the total charge. The No Surprises Act largely prohibits this for certain services, meaning you only pay your in-network cost-sharing.

Q: Does the No Surprises Act apply to self-pay patients?

A: While primarily designed for insured individuals, the Act does require providers to give uninsured/self-pay patients a "Good Faith Estimate" of costs for scheduled services. If a provider or facility bills you at least $400 more than its estimate, you can start a federal dispute within 120 calendar days of the bill. The fee is $25, and it is taken off what you owe if you win.

Q: What if I accidentally sign a waiver giving up my No Surprises Act protections?

A: For certain non-emergency services, you can choose to waive your protections, but only in writing after receiving a notice and a good faith estimate. If you schedule at least 72 hours ahead, you must get the notice at least 72 hours before care. You can never waive protections for ancillary services such as anesthesiology, pathology, radiology, lab work or neonatology, or for unforeseen urgent needs that come up during care. If a form was used for one of those, you may still have grounds to dispute the bill. Read carefully and ask questions before signing anything.

Q: How do I file a complaint about a potential No Surprises Act violation?

A: You can file a complaint with the Centers for Medicare & Medicaid Services (CMS) through their No Surprises Act help desk at 1-800-985-3059 or their website. Your state's Department of Insurance or Attorney General's office may also be able to assist.

Q: What is the Independent Dispute Resolution (IDR) process?

A: If your insurer and an out-of-network provider cannot agree on a payment amount for a service covered by the No Surprises Act, they enter an IDR process. This involves a neutral third party determining the payment, ensuring you are only responsible for your in-network cost-sharing, and protecting you from the billing dispute between the provider and insurer.

Sources

• CMS, medical bill rights and the No Surprises Help Desk: cms.gov
• CMS, dispute a medical bill (uninsured and self-pay): cms.gov
• CMS, No Surprises Act overview of key consumer protections: cms.gov
• CMS, standard notice and consent documents under the No Surprises Act: cms.gov
• KFF, about 1 in 6 emergency visits and hospital stays had at least one out-of-network charge in 2017: kff.org