What is the No Surprises Act? 

The No Surprises Act (Act) is a part of the Consolidated Appropriations Act of 2021 (CAA). The CAA was passed by the U.S. Congress in December 2020. The Act portion of the legislation addresses surprise medical billing by healthcare providers and other member protections. 

The Act provides broad protection for patients from being balanced billed for: 

  • Emergency and stabilization services delivered by out-of-network providers or facilities 
  • Emergency transport by out-of-network air ambulance providers
  • Non-emergency ancillary services (e.g., anesthesia, lab services, etc.) provided by out-of-network providers when the primary service (e.g., surgery, etc.) is provided by an in-network provider, unless the patient agrees in advance to accept the charges

The Act also requires health plans and providers to give cost estimates in advance for planned services and for health plans to make price transparency tools and provider directories available so members can more easily shop for services. In certain circumstances, the Act requires health plans to continue to cover services with providers that have left a plan’s network for up to 90 days. This will allow patients to finish in-progress care before they transition to a new in-network provider.  

When did the new rules take effect? 

The out-of-network billing protections became effective starting January 1, 2022, for the three types of services listed above. 

While the Act says that all new provisions were to go into effect January 1, 2022, the three federal agencies charged with writing the rules to implement the Act — the Department of Health and Human Services, the Department of Labor, and the Department of Treasury — all acknowledged they needed additional time to write complete rules and that plans also needed more time to fully implement the rules. 

The three agencies are continuing to work on rules related to advance cost estimates, called Advance Explanations of Benefits (A-EOBs), as well as new rules related to transparency tools and provider listings.  

When balance billing isn't allowed?

You are only responsible for paying your share of the cost (copayments, coinsurance, and deductible that you would pay if the provider or facility was In-Network). Your health plan will pay any additional costs to out-of-network providers and facilities directly. 

Generally your health plan must:

  • Cover emergency services without requiring you to get approval for services in advance (also known as "prior authorization")
  • Cover emergency services by out-of-network providers
  • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit
     

What are my rights? 

The Act protects you from unexpected out-of-network bills from:

  • Emergency room visits: When you go to the emergency room, you're protected from unexpected out-of-network charges ("surprise bills") for emergency medical services in most cases. You can't be charged any more for emergency medical services than the in-network "cost sharing" rate
  • Planned, non-emergency room care: You may be seen by an out-of-network provider while getting care at an in-network facility. You're protected from out-of-network charges when you get care related to a visit to an in-network hospital, hospital outpatient department, or ambulatory surgical center
  • Air ambulance services

If you use Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE, these plans already protect you from some unexpected out-of-network bills.

Check your Schedule of Benefits to see your out-of-pocket costs for services.

Note: Exceptions

Ground ambulance services

Generally, ground ambulance services aren't covered by billing protections in the No Surprises Act. You may still be charged beyond your in-network cost share for an out-of-network provider.

Vision-only and dental-only insurance

These balance billing protections generally don't apply to vision-only and dental-only insurance plans.

 

Resources:

The Centers for Medicare and Medicaid Services (a federal entity) has put out information on its website regarding the Act: