No Surprises Act
for Fair Billing

The No Surprises Act is a federal law designed to protect you from surprise medical bills and excess costs. This means that when you receive care from an out-of-network provider, you have rights that keep you safe from balance and surprise billing.

When you get emergency medical care or see an out-of-network provider at an in-network hospital or an ambulatory surgical center, you have protections against balance billing. In other words, this means that you should not be required to pay more than your plan’s copayments, coinsurance, and/or deductible.

Balance & Surprise Billing

When you see a medical professional that is out of network for your insurance plan, you often have to pay for certain out-of-pocket costs (like a copayment, coinsurance, or a deductible). If the provider or the entire facility is completely out of network for your health plan, you might be responsible for additional costs.

Out-of-network providers sometimes will bill you for the amount left for the full charge of the service minus what your plan pays. This is called “balance billing,” and is often an amount that is more than you’d pay for the same services from an in-network provider. It might also not count toward your deductible or annual limit for out-of-pocket expenses.

Surprise billing is an unexpected additional cost that usually happens when you cannot control your care providers. This might happen during an emergency or if one of the care providers at your in-network facility is out of network. These costs could range into the thousands.

Protections from Balance Billing

You have protections from balance billing in the following situations:

If you must receive emergency care and go to an out-of-network provider or facility, they cannot bill you any more than your health plan’s in-network cost-sharing amount. This includes copayments, coinsurance, and deductibles. You cannot be balance billed for these emergency services, or services you get once your condition returns to stable. The only scenario in which you can be balance billed is if you give written consent to give up these protections for post-stabalization services.

Emergency Services:

Certain Services at In-Network Hospitals or Ambulatory Surgical Centers

If you visit a hospital or ambulatory surgical center that is in-network but see a provider who is out of network, you cannot be balance billed for their services. The most those providers can 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. Providers also may not ask you to give up these balance bill protections. The only way for providers to balance bill you is if you give written consent to give up these protections.

Please note:

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

Additional Protections

When balance billing isn’t allowed, you also have these protections:

You are only required to pay your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.

Generally, your health plan must:

Cover emergency services without requiring you to get approval for services in advance (also known as “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 in-network deductible and out-of-pocket limit.