The No Surprises Act limits what privately insured patients have to pay for covered services that they inadvertently receive from providers that are out-of-network. Surprise out-of-network bills protected under federal law include those for  emergency services provided in hospitals and freestanding emergency rooms. No Surprises Act protections also apply to non-emergency services provided by nonparticipating providers during a visit at an in-network hospital, hospital outpatient department or ambulatory surgical center, and to air ambulance services provided by out-of-network air ambulance service providers. The law does not limit what privately insured patients have to pay for other out-of-network services.

The law requires that private health plans cover surprise out-of-network bills and apply in-network cost sharing. The out-of-network providers are prohibited from billing patients for more than this in-network cost sharing amount for a surprise medical bill.

Generally, health plans will only reimburse up to an amount they consider reasonable (or allowed) for a given service. In-network providers typically contract to accept that allowed amount and agree to never bill the patient more than the allowed amount for a service, whereas out-of-network providers commonly balance bill patients for any difference between the amount a plan allows and the full undiscounted charge. The No Surprises Act prohibits balance billing by out-of-network providers and facilities for all protected surprise medical bills.

Ground ambulance services are not covered yet under federal law, though state surprise medical bill laws do apply to ground ambulance services in some states

Since 2010 when the Affordable Care Act was enacted, most private plans have been required to cover emergency services without regard to whether care was provided in-network. Federal regulators have since observed that some plans were using reasons other than whether a prudent layperson would consider their condition to be a medical emergency to deny coverage for emergency services, including those listed in the question above, and so clarified that these reasons may not be used to deny coverage for emergency care.

Under the regulations, the in-network hospital “visit” includes items and services furnished as part of that visit, regardless of whether the provider furnishing such service is physically at the facility.

In the scenario described, the No Surprises Act prohibits out-of-network providers from billing patients for more than the amount of cost sharing (deductible, copay, etc.) that would have applied had the care been provided by an in-network provider, or face fines as high as $10,000 per violation. To follow this rule, out-of-network providers of all emergency care and for any care provided at an in-network hospital will need to find out the applicable in-network cost sharing amount. The law requires health plans to give this information to out-of-network providers and to notify patients of the same information on their explanation of benefits (EOB) statement.

If you picked a, you should know that federal regulations do require out-of-network providers to provide insured consumers with a written summary of their surprise billing protections.  This explanatory notice must be given no later than the time when the provider requests payment from the patient, but federal regulations specify it does not have to be included with the provider’s bill.  In any event, an out-of-network provider that does not follow billing limitations also might not follow notice requirements.  As a result, when it comes to bills for any emergency care or any care provided while at an in-network hospital, patients should first check their EOB to be sure that the provider bill matches the amount of in-network cost sharing the health plan says they owe.  If the amounts are different, patients should complain.  A national complaints system has been established.  Consumers can reach it online at https://www.cms.gov/nosurprises or by calling the national Help Desk at 1-800-985-3059 from 8 am to 8 pm EST, 7 days a week.

Private plans are required to cover out-of-network emergency services and out-of-network non-emergency services provided at in-network hospitals unless such services would otherwise be excluded from coverage under the plan. In-network cost sharing must be applied. Plans must notify enrollees of their surprise billing protections and the in-network cost sharing amount that applies to each surprise medical bill. The EOB also must provide contact information about Consumer Assistance Programs that can help file appeals and resolve claims problems. Finally, plans also must inform the out-of-network provider of the in-network cost sharing amount applicable to surprise medical bills.

The No Surprises Act requires that consumers have the right to appeal disputes with health plans over whether a bill is subject to the consumer protections of the No Surprises Act, including the right to an independent external appeal if the health plan upholds its original decision.  Health plan denial notices are required to provide contact information for state Consumer Assistance Programs (CAPs) and notice that CAPs can help consumers file appeals.

Patients can be asked in advance by some out-of-network providers, including surgeons, to waive their balance billing protections for non-emergency services provided at in-network hospitals. Written consent must be given at least 72 hours in advance, or if the procedure is scheduled sooner, at least 3 hours in advance. The waiver form must include a description of services to be provided and a good faith estimate of what the out-of-network provider’s charge will be. Consent must be given voluntarily. These waivers are never allowed for emergency care or for air ambulance services. In the case of non-emergency care provided at in-network facilities, waivers are never allowed for items and services related to anesthesiology, pathology, radiology, neonatology, nor for services provided by assistant surgeons, hospitalists, and intensivists, nor for any other items and services provided by a nonparticipating provider if there is no participating provider who can furnish such item or service at such facility. These waivers also are never allowed for items and services furnished as a result of unforeseen, urgent medical needs that arise at the time an item or service is furnished.

The IDR process is between the health plan and the out-of-network provider or facility. Once the patient pays the in-network cost sharing amount for a surprise medical bill, they have no further responsibility.