How the No Surprises Act Protects Consumers

With the No Surprises Act that went into effect Jan. 1, new federal protections shield millions of consumers from surprise medical bills, which are unexpected bills from out-of-network providers, out-of-network facilities or out-of-network air ambulance providers. The protections ban surprise billing in private insurance for most emergency care and many instances of nonemergency care. They also require that uninsured and self-pay patients receive key information, including overviews of anticipated costs and details about their rights.

These protections will also promote competition in healthcare and other sectors of the American economy. “The No Surprises Act is the most critical consumer protection law since the Affordable Care Act,” said Health and Human Services (HHS) Secretary Xavier Becerra. “After years of bipartisan effort, we are finally providing hardworking Americans with the federal guardrails needed to shield them from surprise medical bills. We are taking patients out of the middle of the food fight between insurers and providers and ensuring they aren’t met with eye-popping, bankruptcy-inducing medical bills. This is the right thing to do, and it supports President Biden’s vision of creating a more transparent, competitive and fair healthcare system.”

A recent report from the HHS Office of the Assistant Secretary for Planning and Evaluation reviewed key evidence on surprise billing and the need for the consumer protections in the No Surprises Act. The report showed surprise billing is common among those with private insurance. Nearly one in five patients who go to the emergency room, have an elective surgery or give birth in a hospital receive surprise bills, with average costs ranging from $750 to $2,600 per episode.

For people who have health coverage through an employer, a Health Insurance Marketplace or an individual health plan purchased directly from an insurer, the rules took effect Jan. 1. These rules:

• Ban surprise bills any time emergency care is received, and require cost-sharing for these services such as co-pays that are always based on in-network rates, even when care is received without prior authorization.

• Ban surprise bills from certain out-of-network providers if an individual goes to an in-network hospital for a procedure. This means cost-sharing for certain additional services during the visit will generally be based on in-network rates.

• Require providers and facilities to share with patients easy-to-understand notices that explain the applicable billing protections and who to contact if they have concerns that a provider or facility has violated the new surprise billing protections.

For people who do not have health insurance or pay for care on their own (also known as “self-paying”), the rules that took effect Jan. 1 require most providers to give a “good faith estimate” of costs before providing nonemergency care. The good faith estimate must include expected charges for the primary item or service, as well as any other items or services that would reasonably be expected. For example, for an uninsured or self-pay consumer getting surgery, the estimate would include the cost of the surgery, as well as any labs, other tests and anesthesia that might be administered during the procedure. Uninsured or self-pay consumers who receive a final bill that exceeds the good faith estimate by $400 or more can dispute the final charges.

Both insured and uninsured/self-pay individuals who are concerned their rights have been violated now have access to a host of tools, including a help desk (available at 800-985-3059 from 8 a.m. to 8 p.m. EST seven days a week; TTY 800-985-3059) and webpage (CMS.gov/nosurprises), where more details on registering potential violations can be found.