No Surprises Act

About

Starting from January 1, 2022, the No Surprises Act (NSA) shields you from unexpected bills if you are covered by a group health plan or have group or individual health insurance. Additionally, the NSA prohibits receiving surprise bills for emergency services provided by an out-of-network provider or facility, without prior authorization.

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service, called “balance billing.”

“Surprise billing” is an unexpected balance bill which can occur when you receive treatment at an in- network facility but are unexpectedly treated by an out-of-network provider.

  •  Emergency services
  •  Certain services at an in-network hospital or ambulatory surgical center
    • This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
    • If you get other types of services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network

  • You’re only responsible for paying your share of the cost (like the 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
    • Cover emergency services by out-of-network providers.
    • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
    • Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

  • The U.S. Center for Medicare & Medicaid Services (CMS) at 800-985-3095 or visit  www.cms.gov/nosurprises/consumers for more information about your rights under federal law. 
  • The Texas Department of Ihnsurance 800-252-3439 or visit https://www.tdi.texas.gov/medical-billing/surprise-balance-billing.html for more information about your rights under Texas law.

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