WHAT YOU SHOULD KNOW

The No Surprises Act

The No Surprises Act (NSA) went into effect on January 1, 2022 and has implications for patients, employers, providers and health plans. When federal law applies, it prohibits medical balance bills for many, but not all, out-of-network services when the member cannot control where or who they receive care from.

Although the NSA prohibits surprise billing for many out-of-network health care services, including most emergency situations, there will still be situations where people will not be protected.

WHAT THE NSA COVERS

The No Surprises Act focuses on three main areas:

1

Prohibits surprise medical billing for out-of-network emergency and air ambulance services.

2

Prohibits surprise medical billing for services performed by out-of-network providers at an in-network facility.

3

Establishes a dispute resolution process for providers and insurers.

 

WHAT THE NSA DOES NOT COVER

Not all health care situations are covered

In general, if a patient chooses to receive care out-of-network, The No Surprises Act will not apply.

So, if you choose to see a doctor or specialist who is not in-network, The No Surprises Act and its protections will not apply, and you may face much higher costs than if you chose a network provider.

The No Surprises Act also does not protect patients from balance billing for ground ambulance services, or when the law’s notice and consent requirements are met.

 

NSA BY THE NUMBERS

45%

of Americans worry that a major health event will bankrupt them.*

85%

of out-of-network medical bills come from situations that won’t be covered by the No Surprises Act.^

40%

of people who received an out-of-network bill report costs over $500.*

  • * Source: KFF.org
    ^ Based on UHC commercial claims data from 2022-2023.

No Surprises Act FAQs

  • Under the law, out-of-network providers are prohibited from pursuing members directly for balance bills in situations where they have little or no control over who provides their care — such as for all emergency services (except ground ambulance), or when an out-of-network provider is involved in their care while they are at an in-network facility.

    If a patient receives a service covered by the No Surprises Act, the law caps the patient’s cost share to what it would be if the services were provided in-network.

  • Patients are protected from balance bills when they receive:

    • Out-of-network emergency services, including air ambulance (but not ground ambulance)
    • Covered medical items and services performed by an out-of-network provider at an in-network facility (unless non-ancillary services and the provider follows the notice and consent process)
    • Out-of-network non-emergency, ancillary services* provided at in-network facility

     

    * Ancillary services include:

    • Emergency medicine, anesthesiology, pathology, radiology, neonatology
    • Certain diagnostic services (like radiology and lab tests)
    • Items and services provided by other specialty doctors
    • Items and services provided by an out-of-network provider if there is no in-network provider that can provide that service
    • Non-emergency, non-ancillary services provided at an in-network facility when the provider did not get prior consent as required

     

    For the above services, a member’s cost-share (in other words, your coinsurance, copay, deductible):

    • Is the same as it would have been if the service was provided in-network
    • Counts toward your in-network deductible
    • Counts toward your out-of-pocket maximum

  • You can find an explanation of the out-of-network laws currently in place in your state on The Commonwealth Fund website. The No Surprises Act may not pre-empt state balance billing laws that establish a process for determining out-of-network reimbursement for covered items and services for insurers subject to the state’s law.

  • For detailed information on NSA requirements for providers, visit CMS.gov.

 

CONTACT US

We can help

Have a question for Naviguard or want to learn more about our services to help manage out-of-network health care costs? Don’t hesitate to reach out.

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