No Surprises Act

Effective January 1, 2022, the No Surprises Act, which Congress passed as part of the Consolidated Appropriations Act of 2021, is designed to protect patients from surprise bills for emergency services at out-of-network facilities or for out-of-network providers at in-network facilities, holding them liable only for in-network cost-sharing amounts. The No Surprises Act also enables uninsured patients to receive a good faith estimate of the cost of care.

Learn More

For more information, visit the Centers for Medicare & Medicaid Services or call (800) 935-3059.

Patient Protection for Out-Of-Network Billing

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that is not in your health plan’s network.

“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan.

 

Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency services and related care.

If you have an emergency medical condition and get emergency services from an out-of- network provider or facility, the most the provider or facility may bill you is your plan’s in- network cost sharing amount (such as copayments and coinsurance). You cannot be balance billed for these emergency services. This includes services you may get after you’re in stable condition unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
 

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may 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. These providers cannot balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers cannot balance bill you unless you give written consent and give up your protections.

 

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

When balance billing is not allowed, you also have the following protections:

You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility were in-network). Your health plan will pay out-of-network providers and facilities directly.

Your health plan generally must:

  • Cover emergency services without requiring you to get approval for services in advance (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 in-network out-of-pocket.

If you believe you have been wrongly billed, you may call the federal agencies responsible for enforcing the federal balance billing protection law at: 1 (800) 985-3059 or St. Elizabeth Physicians Customer Service Department at: (859) 344-5555.

Good Faith Estimates

You are generally considered an uninsured or self-pay individual if you do not have health insurance or do not plan to use your insurance to pay for a medical item or service. If you are an uninsured or self-pay individual, a provider or facility must give you a “good faith estimate” detailing what you may be charged before you receive the item or service. If you schedule an item or service at least 3 business days before the date you will receive the item or service, you must be given a good faith estimate no later than 1 business day after scheduling. If you schedule the item or service at least 10 business days before the date you will receive it, or request cost information about an item or service, the provider or facility must give you a good faith estimate no later than 3 business days after scheduling or requesting.

The good faith estimate will include:

  • A list of items and services that the scheduling provider or facility reasonably expects to provide you for that period of care.
  • In 2022, the good faith estimate may not include all expected charges for items and services from a co-provider or co-facility for items and services that are usually expected to be provided along with the primary item(s) or service(s). This means, for example, that until January 1, 2023, if you schedule a knee replacement surgery with a particular surgeon, your surgeon’s good faith estimate may not include the expected charges from your anesthesiologist. You may however request a good faith estimate directly from a co-provider or co-facility.
  • Applicable diagnosis codes and service codes.
  • A notification that if the billed charges are higher than the good faith estimate, you can ask your provider or facility to update the bill to match the good faith estimate, ask to negotiate the bill, or ask if there is financial assistance available.
  • Information on how to dispute your bill if it is at least $400 higher for any provider or facility than the good faith estimate you received from that provider or facility.