FAIR Health Consumer Access

Surprise Billing: Your Rights

Have you ever received a medical bill out of the blue? These bills can come if you unknowingly see a doctor who’s not in your health plan’s network. Do you know what your rights are and how to dispute a “surprise” bill? This article will explain how in- and out-of-network care affects your medical bill. It will tell you about surprise bills and the No Surprises Act that helps prevent them. It will also explain who’s protected by surprise billing laws, what to do if you get a surprise bill and how to get help to pay your surprise bill.

This article doesn’t provide legal advice. Consult a lawyer to discuss your specific legal situation.

In- and Out-of-Network Care and Balance Billing
If you have health insurance, some providers will have contracts with your health plan and are considered “in network,” while others may be “out of network.” See our article on In-Network and Out-of-Network Care to find out more. As a rule, you’ll pay more for out-of-network care than in-network care. Depending on your plan, your insurance may pay nothing for out-of-network care or may pay a smaller share than for in-network care. You’ll have to pay the difference, or balance, between what your plan will pay and what the out-of-network provider charges—known as “balance billing.” Our article on Cost Sharing gives more information.

Surprise Bills and the No Surprises Act (NSA)
Sometimes you can get balance billed even when you think you’re getting in-network care. These “surprise bills” happen when you unknowingly receive care from an out-of-network doctor, even when you choose an in-network hospital. For example, during a hospital visit, you may be cared for by an out-of-network radiologist without realizing it. Find out more in our article about Out-of-Network Docs at In-Network Facilities. Another common way of getting a surprise bill is during a medical emergency when you might not have control over where you receive care or who treats you.

The NSA is a federal law that went into effect on January 1, 2022. It protects against several types of surprise bills. And it states that health plans must agree to regard certain out-of-network providers or places of service as if they were in network. This means that your plan’s cost-sharing copay, coinsurance or deductible for specific out-of-network services can’t be higher than it is for in-network services. And providers must not balance bill patients for protected services.

What’s protected under the NSA?

• Most emergency services, even if the facility or provider is out of network.
• Nonemergency items and services from out-of-network providers at in-network facilities, such as an anesthesiologist or radiologist.
• Services from out-of-network air ambulance service providers.

But the NSA doesn’t prevent you getting balance billed in all cases. In some instances, it doesn’t apply.

What’s not protected under the NSA?

• When you visit an out-of-network facility for nonemergency items or services.
• When the items or services you get are not covered by your health plan.
• When you use ground ambulance services.
• When a provider or facility provides notice to you and gets your consent to waive the surprise billing protections. This is known as the notice and consent exception. Find out more about when this exception applies from the guidelines here.

Are You Protected by Surprise Billing Laws?
NSA protections apply to most people with health insurance. That includes insurance you get through your or your family member’s workplace. And it includes health insurance you get through state and local government employers. It also includes Federal Employees Health Benefits plans and student health plans, as well as individual or group health insurance plans and those from healthcare.gov.

Even if you don’t have health insurance, you have billing protections under the NSA. If you don’t have health insurance or if you self-pay for care, your provider must give you an estimate of how much you have to pay for services beforehand. This is called a “good faith estimate.” The NSA protects you from being billed substantially more than the good faith estimate.

If you have government healthcare such as Medicaid, Medicare, Veterans Affairs healthcare, TRICARE or an Indian Health Service plan, the NSA protections don’t apply. That’s because these plans already have protections against surprise billing.

If you have certain other types of plans, the NSA also doesn’t protect against balance billing. These include short-term, limited-duration health coverage. Other examples are excepted benefits plans (such as standalone dental and vision coverage), disease-specific plans, retiree-only plans or account-based group health plans. Unlike government healthcare, these plans don’t have built-in protections. However, you’re still entitled to the same NSA protections as someone without insurance.

Different states have different protections for consumers regarding surprise bills. Some states have more protections than the NSA. Others have less protection than the NSA. The NSA comes into play if the state laws don’t cover a surprise billing situation, but the NSA does. For example, emergency services may be defined differently by a state compared to the NSA. In that case, some services may be protected by the state law, while others are protected under the NSA. Ground ambulance services are a common source of surprise bills, but they aren’t protected under the NSA. However, some states offer their own protections for ground ambulance bills. Contact your state’s insurance department to find out what surprise billing protections are offered where you are. For information about New York State’s surprise billing law, see our article here.

What to Do If You Get a Surprise Bill
If you use health insurance: Check the bill closely for mistakes. Compare it with your health plan’s Explanation of Benefits (EOB)—it should match. If your bill is higher than it should be, call your provider and let them know. They may adjust the bill. Also, call your health plan to discuss your cost sharing in light of your state’s laws and/or the NSA. If you’re not sure if the NSA applies to your bill, call the Centers for Medicare & Medicaid Services (CMS) No Surprises Help Desk at 1-800-985-3059 to find out. They can also help you figure out if your state’s laws protect you. If your state’s laws don’t apply and the NSA does, but your provider or plan disagrees, you can file a complaint. Find out more here.

If you don’t use health insurance: If your bill’s at least $400 higher than your provider’s good faith estimate, you can challenge it under the NSA. To do so, you can use the patient-provider dispute resolution process. This involves an outside organization known as an independent dispute resolution (IDR) entity. The IDR entity will help to resolve the dispute. During the dispute process, your provider can’t send your bill to collections. And they can’t collect late fees either. Find out more here.

Either way, you and your provider can still negotiate the bill, even if you’ve filed a complaint or started working with an IDR entity. Remember to keep all related EOBs, medical bills and good faith estimates. You may need to refer to them later.

What If You Still Need Help to Pay Your Medical Bill?
If your unexpected medical bill doesn’t fall under any surprise billing protections, there are other ways to get help to pay it.

Ask your provider for a discount: If the bill seems too high, ask for a discount. Providers are under no obligation to reduce bills, but many do.

Look up local costs in your area: Check out our FH^® Medical Cost Lookup Tool or our FH^® Dental Cost Lookup Tool to find out how much services typically cost in your area. If your bill is more than our estimate, use the estimate to negotiate with your provider.

Apply for financial assistance: Many hospitals offer financial assistance programs. You can look them up online and find out how to apply.

Find a patient advocate organization: Organizations like the Patient Advocate Foundation can help with financial aid and advice.

Resources
The CMS No Surprises Act Toolkit for Consumer Advocates has a lot of information on rules and policies around the NSA. It also has a section on key consumer protections.

The CMS No Surprises Act Consumer Advocate Toolkit Glossary can help you find definitions of NSA terms.

A list of states that have a Consumer Assistance Program can help you find answers to health insurance questions in your state.