How the New No Surprises Act Protects You Against Unexpected Medical Bills

For years, insured patients who needed emergency treatment or hospitalization had another emergency to worry about: Would they even be able to pay the bill?

That’s because until 2022, it was perfectly legal for out-of-network providers who participated in your care — say, the anesthesiologist who monitored your surgery or the air ambulance that got you there — to charge you for the services that you very much needed. Instead of accepting your insurance plan’s discounted rate, they could bill you for the difference between that and their full fee. But thanks to the No Surprises Act, that practice (known as balance billing) is now outlawed unless you provide consent (more on this below).

The protection couldn’t have come soon enough. A 2020 study by the Peterson-KFF Health System Tracker estimated that 1 in 5 emergency claims and 1 in 6 in-network hospitalizations included at least one surprise bill for out-of-network services. And in 13% of cases, those bills amounted to more than $2,000 in expenses that the insurer wouldn’t pay.

Now that the No Surprises Act is in full effect, it’s important to understand exactly what it can — and can’t — do for you. We spoke to an expert to get all the details so you can reap the law’s full protection.

What does the No Surprises Act cover?

The law applies to people with private health insurance, and it covers most emergency care in:

• an air ambulance
• a hospital ER
• a freestanding emergency room

“Everything that happens until the patient is stabilized is covered by the law,” says Myra Simon, a health insurance adviser at Avalere Health. The protections still apply even if the final diagnosis determined by the emergency room is not something most people would consider an emergency. So if your severe abdominal pain turns out to be gas, not appendicitis, your plan can’t deny coverage of the service just because of the final diagnosis.

The No Surprises Act also applies to certain non-emergency care. If you have a planned procedure at an in-network hospital or facility, no one who treats you there can charge more than the in-network rates, regardless of whether they’re individually part of your plan.

Read any paperwork providers give before or at the appointment closely. According to Simon, this includes forms you might fill out online in advance of an appointment. If an out-of-network specialist is going to provide care, they need to provide a written consent form along with a cost estimate and a list of other providers who are in-network within 72 hours of treatment.

“If you are asked to consent to receiving out-of-network care in the forms, you can decline,” says Simon. “If you need information in a language other than English and/or have a disability and need accommodations to access the information, you have a right to support in another language, and/or accommodations for any disabilities.”

What doesn’t the No Surprises Act cover?

There are a few important costs and facilities that the law does not cover. Those include:

• Deductibles
• Copays and coinsurance
• Ground ambulances (even in emergencies)
• Out-of-network urgent care centers
• Birthing centers
• Nursing homes

If you think there’s an error with your situation, you can also file a complaint. Patients with a complaint about a surprise bill can contact a new federal hotline, called the No Surprises Help Desk, at 800-985-3059.

How to save on all your medical costs

Staying in network is one of the best ways to avoid unnecessary expenses. Here are four ways to do it:

1. Call your insurance provider before scheduling your appointment. “Checking that providers are in network before the appointment is the best way to reduce the chance of a surprise bill,” says Simon.

This does two things: It gives you confirmation that your medical care is in fact in network, and it gives you the opportunity to go on record that you checked. “Having a record that you checked will help you appeal any surprise bills if there was a mistake in the plan’s directory,” adds Simon. Take screenshots of the provider directory or make notes about phone conversations that you can find later if you need them.

“To be extra sure, when you schedule the appointment, ask the person scheduling your appointment at the provider’s office to double-check that they take your insurance,” says Simon.

2. Call the billing department. Besides calling your doctor’s office, you should also connect with your provider’s billing department to get expense questions answered.

For planned medical expenses, speak with the billing department to get a gauge of typical in-network repricing and discounts for the procedure to estimate out-of-pocket expenses.

3. Confirm that your treatment or procedure is a covered service. “Even at an in-network doctor, plans only cover specific services,” says Simon. “And if you haven’t met your deductible [the amount you pay before your insurance coverage kicks in], you’ll want to understand how much you’ll owe.”

Once you’ve got a handle on your deductible, you’ll want to find out if there’s any cost-sharing on the procedure you’re having. For certain procedures, your plan may cover a certain percentage, and you may be responsible for a certain amount as well. You may be able to find this information on your plan’s website, or just contact them directly to ask, says Simon.

4. Do an annual coverage review. From year to year, your insurance and/or medical care providers may change what they cover (and don’t cover). Do an annual review of your coverage to determine if your caregivers are still in network.

Additional sources
No Surprises Act basics: Centers for Medicare and Medicaid Services (2022). “Surprise billing & protecting consumers” and “No Surprises: Understand your rights against surprise medical bills”
Surprise billing statistics: Peterson-KFF Health System Tracker (2020). “An examination of surprise medical bills and proposals to protect consumers from them”