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.

Sus derechos y protecciones contra las facturas médicas sorpresas

¿Qué es la “facturación de saldo” (a veces llamada “facturación sorpresa”)?

Cuando consulta a un médico u otro proveedor de atención médica, es posible que deba ciertos gastos de su bolsillo, como un copago, un coseguro o un deducible. Puede que tenga otros gastos o que tenga que pagar toda la factura si consulta a un proveedor o visita un centro de atención médica que no está en la red de su plan médico.

“Fuera de la red” se refiere a los proveedores y centros que no firmaron un contrato con su plan médico. Puede que a los proveedores fuera de la red le permitan facturarle la diferencia entre lo que su plan acordó pagar y la cantidad total que se cobra por un servicio. Esto se llama “facturación de saldo”. Es probable que esta cantidad sea mayor que los costos dentro de la red por el mismo servicio y puede que no cuente para su límite anual de gastos de bolsillo.

La “facturación sorpresa” es una factura de saldo imprevista. Esto puede suceder cuando no puede controlar quién participa en su atención, como cuando tiene una emergencia o cuando programa una visita en un centro dentro de la red, pero, de manera imprevista, lo atiende un proveedor fuera de la red.

Está protegido contra la facturación de saldo para:

Servicios de emergencia

Si tiene una condición médica de emergencia y recibe servicios de emergencia de un proveedor o centro fuera de la red, lo máximo que el proveedor o el centro puede facturarle es la cantidad de costo compartido dentro de la red de su plan (como copagos y coseguro). No le pueden facturar el saldo de estos servicios de emergencia. Esto incluye los servicios que podría recibir después de que esté estable a menos que dé su consentimiento por escrito y renuncie a sus protecciones para que no le facturen el saldo de estos servicios después de la estabilización.

Ciertos servicios en un hospital o centro quirúrgico ambulatorio dentro de la red

Cuando recibe servicios de un hospital o centro quirúrgico ambulatorio dentro de la red, puede que ciertos proveedores estén fuera de la red. En estos casos, lo máximo que esos proveedores pueden facturarle es la cantidad de costo compartido dentro de la red de su plan. Esto se aplica a los servicios de medicina de emergencia, anestesia, patología, radiología, laboratorio, neonatología, cirujano asistente, hospitalista o intensivista. Estos proveedores no pueden facturarle el saldo y no pueden pedirle que renuncie a sus protecciones para que no le facturen el saldo.

Si recibe otros servicios en estos centros dentro de la red, los proveedores fuera de la red no pueden facturarle el saldo a menos que dé su consentimiento por escrito y renuncie a sus protecciones.

Nunca se le pedirá que renuncie a sus protecciones contra la facturación del saldo. Tampoco está obligado a recibir atención fuera de la red. Puede elegir un proveedor o centro dentro de la red de su plan.

Cuando no se permite la facturación de saldo, también tiene las siguientes protecciones:

  • Solo es responsable de pagar su parte del costo (como los copagos, el coseguro y los deducibles que pagaría si el proveedor o el centro estuvieran dentro de la red). Su plan médico pagará directamente a los proveedores y centros fuera de la red.
  • Por lo general, su plan médico debe:
    • Cubrir los servicios de emergencia sin necesidad de que usted obtenga aprobación con antelación para los servicios (autorización previa).
    • Cubrir los servicios de emergencia de proveedores fuera de la red.
    • Basar lo que le debe al proveedor o centro (costos compartidos) en lo que le pagaría a un proveedor o centro dentro de la red y mostrar esa cantidad en su explicación de beneficios.
    • Hacer que toda la cantidad que pague por servicios de emergencia o servicios fuera de la red cuente para su deducible dentro de la red y su límite de gastos de bolsillo dentro de la red.

Si considera que le facturaron erróneamente, puede llamar a las agencias federales responsables de hacer cumplir la ley federal de protección de facturación de saldos al: 1-800-985-3059 o al Departamento de Servicio de atención al cliente (Physicians Customer Service Department) de St. Elizabeth Physicians al: 859-344-5555.
Visite cms.gov/nosurprises/consumers para obtener más información sobre sus derechos según la ley federal.