No Surprises Act

 

The No Surprises Act protects people covered under group and individual health plans
from receiving surprise medical bills when they receive most emergency services, non-
emergency services from out-of-network providers at in-network facilities, and services
from out-of-network air ambulance service providers. It also establishes an independent
dispute resolution process for payment disputes between plans and providers, and
provides new dispute resolution opportunities for uninsured and self-pay individuals
when they receive a medical bill that is substantially greater than the good faith estimate
they get from the provider.

Starting in 2022, there are new protections that prevent surprise medical bills. If you
have private health insurance, these new protections ban the most common types of
surprise bills. If you’re uninsured or you decide not to use your health insurance for a
service, under these protections, you can often get a good faith estimate of the cost of
your care up front, before your visit. If you disagree with your bill, you may be able to
dispute the charges. Here’s what you need to know about your new rights.

What are surprise medical bills?

Before the No Surprises Act, if you had health insurance and received care from an out-
of-network provider or an out-of-network facility, even unknowingly, your health plan
may not have covered the entire out-of-network cost. This could have left you with
higher costs than if you got care from an in-network provider or facility. In addition to any
out-of-network cost sharing you might have owed, the out-of-network provider or facility
could bill you for the difference between the billed charge and the amount your health
plan paid, unless banned by state law. This is called “balance billing.” An unexpected
balance bill from an out-of-network provider is also called a surprise medical bill.
People with Medicare and Medicaid already enjoy these protections and are not at risk
for surprise billing.

What are the new protections if I have health insurance?

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If you get health coverage through your employer, a Health Insurance
Marketplace, or an individual health insurance plan you purchase directly from an
insurance company, these new rules will:
 Ban surprise bills for most emergency services, even if you get them out-of-
network and without approval beforehand (prior authorization).
 Ban out-of-network cost-sharing (like out-of-network coinsurance or copayments)
for most emergency and some non-emergency services. You can’t be charged
more than in-network cost-sharing for these services.
 Ban out-of-network charges and balance bills for certain additional services (like
anesthesiology or radiology) furnished by out-of-network providers as part of a
patient’s visit to an in-network facility.
 Require that health care providers and facilities give you an easy-to-understand
notice explaining the applicable billing protections, who to contact if you have
concerns that a provider or facility has violated the protections, and that patient
consent is required to waive billing protections (i.e., you must receive notice of
and consent to being balance billed by an out-of-network provider).

What if I don’t have health insurance or choose to pay for care on my own without
using my health insurance (also known as “self-paying”)?

If you don’t have insurance or you self-pay for care, in most cases, these new rules
make sure you can get a good faith estimate of how much your care will cost before you
receive it.

What if I’m charged more than my good faith estimate?

For services provided in 2022, you can dispute a medical bill if your final charges are at
least $400 higher than your good faith estimate and you file your dispute claim within
120 days of the date on your bill.

What if I do not have insurance from an employer, a Marketplace, or an individual
plan? Do these new protections apply to me?

Some health insurance coverage programs already have protections against surprise
medical bills. If you have coverage through Medicare, Medicaid, or TRICARE, or receive
care through the Indian Health Services or Veterans Health Administration, you don’t
need to worry because you’re already protected against surprise medical bills from
providers and facilities that participate in these programs.

What if my state has a surprise billing law?

The No Surprises Act supplements state surprise billing laws; it does not supplant them.
The No Surprises Act instead creates a “floor” for consumer protections against surprise
bills from out-of-network providers and related higher cost-sharing responsibility for
patients. So as a general matter, as long as a state’s surprise billing law provides at

least the same level of consumer protections against surprise bills and higher cost-
sharing as does the No Surprises Act and its implementing regulations, the state law
generally will apply. For example, if your state operates its own patient-provider dispute
resolution process that determines appropriate payment rates for self-pay consumers
and Health and Human Services (HHS) has determined that the state’s process meets
or exceeds the minimum requirements under the federal patient-provider dispute
resolution process, then HHS will defer to the state process and would not accept such
disputes into the federal process.

As another example, if your state has an All-payer Model Agreement or another state
law that determines payment amounts to out-of-network providers and facilities for a
service, the All-payer Model Agreement or other state law will generally determine your
cost-sharing amount and the out-of-network payment rate.

Where can I learn more?

Still have questions? Visit CMS.gov/nosurprises, or call the Help Desk at 1-800-985-
3059 for more information. TTY users can call 1-800-985-3059.