Your Rights and Protections Against Surprise Medical Bills

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 services rendered by out-of-network providers at in-network facilities, holding them liable only for in-network cost-sharing amounts. The Act also enables uninsured and self-paying patients to receive a good faith estimate of the cost of care.

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 additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your insurance plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your insurance plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay 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 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. The No Surprises Act prohibits providers from billing patients more than the applicable in-network cost sharing amount in these situations. You’re 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 insurance plan’s network.

Additionally, there may be specific state law requirements that also protect you from balance billing. If you believe you’ve been wrongly billed, you may contact:

U.S. Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (1-800-633-4227) or visit https://www.cms.gov/nosurprises.

Good Faith Estimate

If you don’t have health insurance or are not using insurance, you have the right to receive a “Good Faith Estimate” of the total expected cost of your medical care upon request or when scheduling health care services.

If you schedule a health care item or service at least 3 business days in advance, you are entitled to receive a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, you are entitled to receive a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate:

Visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.