You may have heard stories from friends or in the news about balance bills or surprise bills from health care providers. Starting in 2022, a new federal law, The No Surprises Act, will protect you from many types of surprise bills. Here are the basics about the new protections.

What is Balance Billing?

To start, it will be helpful first to understand the term “balance 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 if you see a provider or visit a health care facility that isn’t in your health plan’s network you may have to pay the entire bill. “Out-of-network” describes providers and facilities that haven’t signed a contract with your health 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 charges for the same service and might not count toward your annual out of pocket limit.

What is Surprise Billing?

“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.

What are the protections?

If you get health coverage through your employer or have an individual or family health plan, these protections apply:

Surprise bills for most emergency services are prohibited, even if you get them out-of-network and/or without approval beforehand.
Out-of-network cost-sharing (like out-of-network coinsurance or copayments) for most emergency and some non-emergency services is prohibited. You can’t be charged more than in-network cost-sharing for these services.
Out-of-network charges and balance bills for supplemental care (like anesthesiology or radiology) by out-of-network providers who work at an in-network facility is prohibited.
Health care providers and facilities must give you an easy-to-understand notice explaining that getting care out-of-network could be more expensive and they must give you options to avoid balance bills. You’re not required to sign this notice or get care out-of-network.
Other protections in the new law require health plans to keep their provider directories updated. They also must limit your copays, coinsurance, or deductibles to in-network amounts if you rely on inaccurate information in a provider directory.
You are not required to use your insurance if the service you need isn’t covered, or it’s less expensive if you pay out of pocket.
When you aren’t using insurance, in most non-emergency cases, providers and facilities must give you a good faith estimate when you schedule care at least 3 business days in advance, or if you ask for one.

If you do not have insurance, you also have protections under the No Surprises Act. To learn more visit: CMS.gov

What about Ground Ambulance bills?

Current law does not include balance billing protections for ground ambulance bills. More information here: CMS.gov

Complaints:

If you’ve received a surprise bill and you believe your health plan is not following the new law, you can file an appeal with your health plan or ask for an external review of its decision. You can also file a complaint with the Minnesota Department of Health or The Minnesota Department of Commerce.

If you believe you’ve been wrongly billed by a medical provider or facility, you may file a complaint with the federal government at Centers for Medicare & Medicaid Services or by calling 1-800-985-3059 For more information please visit: CMS.gov

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For more information, email health.mcs@state.mn.us.