No Surprises Act: Guide to Avoiding Unexpected Medical Bills

By Eliza Kim, LMHC, Intake Coordinator and Resource and Referral Counselor, INTERFACE Referral Service

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“How much will this cost?” If you have ever asked yourself that question before getting medical care, you are not alone. Unexpected medical bills can add stress to an already difficult situation. Knowing what to expect ahead of time can make things a little easier and help you feel more confident about your healthcare decisions.

The federal No Surprises Act (NSA) took effect on January 1, 2022. It was created to help patients better understand their healthcare costs and protect them from certain unexpected medical bills. Before these protections were in place, patients could sometimes receive care from an out-of-network provider without realizing it and then receive a much higher bill than expected. The goal of the law is to give patients more information about their costs before receiving care.

One important protection under the law is the Good Faith Estimate (GFE). If you are uninsured or choose not to use your insurance, you generally have the right to receive an estimate of what your care is expected to cost. Depending on the type of care you receive, the estimate may include the expected cost of services and other charges that are reasonably connected to your treatment. Receiving this information before care begins gives you a chance to review the expected costs and plan ahead. Keep in mind that a Good Faith Estimate is just an estimate. It is not the same as your final bill. Healthcare needs can change, and the cost of care may change as well. If there are significant changes to your treatment or expected charges, your provider may update the estimate. It is also a good idea to keep a copy of your estimate in case you have questions about your bill later.

The law also protects many people with private health insurance who receive certain out-of-network services. These protections generally apply to emergency services and certain non-emergency services provided at in-network hospitals and facilities by out-of-network providers. In these situations, you may be protected from being charged more than the applicable in-network cost-sharing amount. There are also notice and consent requirements in some situations when a patient chooses to receive non-emergency care from an out-of-network provider.

For Massachusetts residents with fully insured health plans, an out-of-network provider generally must provide written information explaining that the provider is out of network and that choosing that provider may result in higher costs. In certain situations, patients must provide written consent before receiving out-of-network, non-emergency services. Patients may also need information about available in-network providers and the expected cost before giving consent. These requirements are intended to help patients understand their choices before agreeing to care that may cost more.

Before receiving care, check whether your healthcare provider and facility are in network with your insurance plan. Insurance provider directories are required to be kept up to date, and patients who rely on incorrect network information may have certain protections if they later receive a bill based on that error. Your insurance card can also provide useful information about your deductible, out-of-pocket limit, and how to contact your insurance company with questions about your coverage.

The No Surprises Act applies to many employer-sponsored and individual health plans, including coverage offered through the Massachusetts Health Connector and health insurance companies licensed in Massachusetts. It generally applies to both fully insured and self-funded employer plans. Some programs, including MassHealth, Medicare, TRICARE, Indian Health Services, and Veterans Health Administration coverage, are not covered by the federal No Surprises Act in the same way. However, people enrolled in these programs may have other federal or state protections.

Massachusetts has its own protections related to balance billing, including those found under M.G.L. c. 176O, §6(a)(4). The federal No Surprises Act adds additional protections in certain situations. If you receive a bill that you believe may violate these protections, or if you are unsure about what you owe, ask questions before paying the bill. Your healthcare provider or insurance company may be able to explain the charges and help you understand your options. You can also contact the appropriate state or federal agency if you need additional help.

For questions or concerns about surprise medical bills, consumers can contact the Centers for Medicare and Medicaid Services (CMS) at 1-800-985-3059. Massachusetts residents can also contact the Massachusetts Division of Insurance at (877) 563-4467 and select Option 2, or email CSSComplaints@mass.gov.

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Before Receiving Care: A Quick Checklist

• Ask how much the service is expected to cost.
• Ask whether the provider or facility is in network with your insurance plan.
• Review your insurance benefits and expected out-of-pocket costs.
• Ask for a Good Faith Estimate if you are uninsured or choosing not to use insurance.
• Keep a copy of your Good Faith Estimate for your records.
• Ask whether the expected cost could change and what might cause the cost to change.
• Review your bills and compare them with your estimate and Explanation of Benefits.
• Ask about any charge you do not understand or that seems higher than expected.
• If your bill is at least $400 higher than your Good Faith Estimate, ask about your dispute resolution options.
• Remember that you can ask questions about the cost of your care before agreeing to services.

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Healthcare and Billing Glossary

• Balance Billing — When an out-of-network provider bills you for the difference between what they charge and what your insurance agrees to pay.
• Balance Billing Protection — Legal protections that may prevent certain healthcare providers from charging patients more than the applicable in-network cost-sharing amount.
• Copayment (Copay) — A set amount you pay for a covered healthcare service, such as a doctor's visit.
• Coinsurance — The percentage of the cost of a covered healthcare service that you pay after meeting your deductible.
• Deductible — The amount you generally must pay for covered healthcare services before your insurance begins paying according to your plan.
• Emergency Services — Medical care needed to evaluate or treat an emergency health condition.
• Explanation of Benefits (EOB) — A document from your insurance company that explains what services were billed, what insurance paid, and what you may owe.
• Good Faith Estimate (GFE) — A written estimate of the expected cost of healthcare services provided to someone who is uninsured or chooses not to use insurance.
• Health Insurance Plan — A plan that helps pay for medical and healthcare services.
• In-Network Provider — A healthcare provider or facility that has an agreement with your insurance company to provide services at negotiated rates.
• No Surprises Act (NSA) — A federal law that provides certain protections against surprise medical bills and requires greater transparency about healthcare costs.
• Out-of-Network Provider — A healthcare provider or facility that does not have an agreement with your insurance company. Using an out-of-network provider may result in higher costs.
• Out-of-Pocket Costs — The amount you are responsible for paying yourself, including deductibles, copayments, and coinsurance.
• Out-of-Pocket Maximum — The most you generally have to pay during a plan year for covered services before your insurance pays 100% of covered benefits, subject to your plan's rules.
• Outpatient Care — Healthcare services that do not require you to stay overnight in a hospital or healthcare facility. Examples include doctor's appointments, counseling, diagnostic testing, and same-day procedures.
• Patient-Provider Dispute Resolution Process — A federal process that may allow eligible uninsured or self-pay patients to dispute certain bills that are substantially higher than their Good Faith Estimate.
• Premium — The amount you pay for your health insurance coverage, usually monthly.
• Prior Authorization — Approval from an insurance company that may be required before certain healthcare services, treatments, or medications are covered.
• Provider Directory — A list maintained by an insurance company showing healthcare providers and facilities that participate in the plan's network.
• Self-Pay Patient — Someone who chooses to pay for healthcare services themselves rather than submitting the services to their insurance.
• Surprise Medical Bill — An unexpected bill, often resulting from receiving care from an out-of-network provider without knowing the provider was out of network.

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References

Centers for Medicare and Medicaid Services. (2022). No Surprises: Understand your rights against surprise medical bills. U.S. Department of Health and Human Services. www.cms.gov/newsroom/fact-sheets/no-surprises-understand-your-rights-against-surprise-medical-bills 

Congressional Research Service. (2021). The No Surprises Act (NSA): Overview of key consumer protections (CRS Report No. R46856). www.congress.gov/crs-product/R46856 

SimplePractice. (2022). Good Faith Estimates and the No Surprises Act. www.simplepractice.com/blog/no-surprises-act-good-faith-estimates/ 

U.S. Department of Labor, Employee Benefits Security Administration. (2022). Avoid surprise healthcare expenses. www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/publications/avoid-surprise-healthcare-expenses