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No Surprises Act Goes into Effect, Expanding Patient Protections

The No Surprises Act, a federal law that protects people who are covered under group and individual health insurance policies from receiving surprise bills in many circumstances, went into effect at the beginning of the year. The law also establishes an independent mechanism to resolve disputes between plans and providers as well as between uninsured patients and providers when they have received a good faith estimate from a provider. 

Many Americans fear getting unexpected medical bills, and this law was passed after years of outrage over surprise bills following emergency procedures. The law covers surprise bills resulting from care from out-of-network providers and facilities in emergency and some non-emergency situations, and when out-of-network practitioners provide care at in-network facilities. It also requires providers and facilities to provide easy-to-understand notices explaining billing protections and practices.

These changes do not directly apply to people with public health insurance like Medicare, Medicaid, TRICARE, the Indian Health Service, or VA benefits, because these people are already protected from balance billing and these types of surprise bills. Since 1997, people with Original Medicare have been protected against surprise billing from opt-out providers under financial liability rules, and such providers must enter into a private contract with the patient in advance of providing care that explains fully that Medicare will not pay for the services. Providers who do not accept assignment may charge more than the Medicare-approved amount but are still limited in the amount above that rate they may charge and are always required to submit the bill to Medicare.

People with Medicare Advantage plans that have networks are also protected from out-of-network surprise and balance billing in several ways—enrollees may not be charged more than in-network cost-sharing for emergency and urgently needed services, including stabilization, medically necessary dialysis when the enrollee is outside of the plan’s service area, or services provided by an in-network provider who works with out-of-network providers, or where an in-network provider has referred or received prior authorization for the referral to an out-of-network provider. 

At Medicare Rights, we support these needed limitations on surprise billing and are glad to see protections extended to people with group and individual coverage. We will continue to urge Congress to extend the reach of surprise billing prohibitions to cover ambulance services and other care that was not covered by the No Surprises Act.

Read the CMS fact sheet about the No Surprise Act.

See a Kaiser Family Foundation explainer video for the new protections.

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