No Suprises Act and Transparency in Coverage

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How you’re protected from surprise medical bills under the No Surprises Act.

Sometimes where and from whom you get health care is out of your control. Like when you need emergency care, or an out-of-network provider is involved in your care without your choice. When this happens, the No Surprises Act may apply, and when it does, you won’t have to pay more than your copay, coinsurance, or deductible.

Frequently asked questions:

Q: What is a surprise bill?

A: When you receive health care services, you may owe copayment, coinsurance or deductible. If an out-of-network provider is involved in your care, you may owe these costs and face additional costs—or even the entire bill.

This is in part because out-of-network providers sometimes bill you for more than your health plan determines it and you (through your copayment, coinsurance or deductible) should pay. This bill is called a surprise bill or a balance bill. Network providers don’t do this. Out-of-network providers sometimes do.

Q: What is an out-of-network provider?

A: An out-of-network provider is one that has not signed a contract with your health plan. Out-of-network providers service rates are likely higher and may not count toward your deductible or out-of-pocket limit. That’s why it’s best to visit network providers whenever possible. Find them anytime at your online member website, or mobile app.

Q: When am I now protected from surprise bills?

A: You’re protected from surprise bills when you receive:

• Out-of-network emergency services, including air ambulance (but not ground ambulance)
• Out-of-network non-emergency, ancillary services* provided at in-network facility
• Non-emergency, non-ancillary services provided at in-network facility, and the provider did not get your prior consent in the way the No Surprises act requires.

And, for the above services, your health plan must ensure your cost-share (in other words, your coinsurance, copay, deductible):

• Be the same as it would have been if the service was provided in-network.
• Be based on what your plan would pay an in-network provider.
• Count toward your in-network deductible.
• Count toward your out-of-pocket maximum.

*Ancillary services include services related to emergency medicine, anesthesiology, pathology, radiology and neonatology; certain diagnostic services (including radiology and laboratory services); items and services provided by other specialty practitioners; and items and services provided by an out-of-network provider if there is no in-network provider that can provide that service.

Remember: Out-of-network providers may not ask you to give up your protections against surprise billing, and you are never required to do so.

Q: If I get a surprise bill in one of these situations, what should I do?

A: In these situations, you are only responsible to pay your copay, coinsurance, or deductible that would have been charged if you had seen a provider in your plan’s network. That means, you should not get—and, if you get, you do not need to pay—a balance or a surprise bill from an out-of-network provider.

Q: What if I choose to see an out-of-network provider or visit an out-of-network facility outside of these situations?

A: Choosing to visit an out-of-network provider or facility under different circumstances means you may face paying the entire bill, because providers are generally not prohibited by law from sending you a surprise bill. That’s why it’s so important to stay in your network whenever possible.

Q: What if I have questions?

A: We’re here for you. If you have questions about a provider’s network status or you believe you’ve been wrongly billed, please contact the telephone number on the back of your ID card.

Visit  www.cms.gov/nosuprises for more information about your rights under federal law.