The No Surprises Act: how you're protected from surprise medical bills

What a surprise bill is

A surprise medical bill usually happens when you get care from a doctor or facility that isn't in your health plan's network, often without knowing it. In the past, that provider could bill you for the difference between what it charged and what your plan paid. This is called balance billing.

The federal No Surprises Act took effect in 2022 to stop many of these bills. It covers most kinds of private health insurance, including job-based plans and plans bought on your own. It also gives people without insurance, or who choose not to use it, a right to a cost estimate before care.

What the law protects

If you have private insurance, the law protects you in three main situations:

• Emergency care. Your plan must treat emergency services as in-network, even at an out-of-network emergency room. You pay no more than your in-network copay, coinsurance or deductible.
• Non-emergency care at an in-network facility. If you go to an in-network hospital, hospital outpatient department or ambulatory surgery center, an out-of-network doctor working there generally can't balance bill you.
• Air ambulance services. Out-of-network air ambulance companies can't balance bill you either.

What it does not cover

Ground ambulances are the big gap. Congress left them out of the law's billing protections, so a ground ambulance can still send you an out-of-network bill unless your state has its own rule. Some states do, so check with your state insurance department if you get one.

The protections also don't apply to some kinds of coverage, including short-term limited-duration plans, health care sharing ministries, fixed indemnity plans such as hospital indemnity insurance, and stand-alone dental or vision plans. Medicare, Medicaid, TRICARE, VA care and the Indian Health Service have their own protections against unexpected out-of-network bills.

Be careful what you sign

For some planned, non-emergency care, an out-of-network provider can ask you to give up your protections by signing a notice and consent form. You never have to sign it. If you do sign, you may be billed at out-of-network rates.

There are firm limits on this. The form must come at least 72 hours before the appointment, or on the day you schedule if the visit is less than 72 hours away, or at least 3 hours ahead for same-day care. And some providers can never ask you to waive your rights for care at an in-network facility. These include emergency medicine, anesthesiology, pathology, radiology and neonatology, plus assistant surgeons, hospitalists, intensivists, and lab and imaging services. No one can ask you to waive protections for emergency care before you are stable.

If you're uninsured or paying yourself

If you don't have insurance, or you choose not to bill your insurance, providers generally must give you a good faith estimate of the expected charges. You get one when you schedule care, and you can ask for one any time you're shopping around.

Timing rules apply. If you schedule at least 3 business days ahead, the estimate is due within 1 business day of scheduling. If you schedule at least 10 business days ahead, or you simply ask for cost information, it's due within 3 business days. Keep a copy of every estimate you receive.

Disputing a bill that's far above the estimate

If your final bill is at least $400 more than the good faith estimate from a given provider or facility, you can start a federal patient-provider dispute resolution process. Here is how it works:

• You must start within 120 calendar days of the date on the original bill.
• There is a $25 administrative fee to start. CMS says this amount could change in future years.
• The $400 test is applied separately to each provider or facility on the estimate.
• While the dispute is open, the provider can't send your bill to collections, must pause collections already underway, can't charge late fees on the disputed amount, and can't retaliate against you.
• You and the provider can keep talking and settle at any point before a decision.

How to file a complaint

If you think a provider, facility or insurer broke the surprise billing rules, you can complain to the No Surprises Help Desk run by the Centers for Medicare & Medicaid Services (CMS). Call 1-800-985-3059 or file online through CMS's medical bill rights website. Help is available in English, Spanish and many other languages.

You don't need every document to file, but these help:

• The medical bill, plus a photo of your insurance card if you used insurance.
• Your explanation of benefits (EOB) from your plan, if you got one.
• Any good faith estimate, signed notice and consent form, letters with the provider, or appeal decisions.
• Write down your confirmation number. CMS says it will contact you within 60 days if it needs more information, and it may refer your complaint to a state or other federal agency.

Practical steps when a bill looks wrong

Compare the bill with your EOB before you pay. If an out-of-network charge shows up for emergency care or for a doctor you didn't choose at an in-network hospital, call the provider's billing office and say you believe the No Surprises Act applies. Ask them to rebill at in-network cost sharing.

If they won't fix it, call your insurer, then the Help Desk. Don't ignore the bill while you wait; keep notes of every call with the date and the person's name. This is general information, not legal advice. Your state may offer added protections, especially for ground ambulance bills.