No Surprise Act

What is balance billing?

Balance billing occurs when a health care provider bills a patient after the patient’s health insurance company has paid its portion. The balance bill is for the difference between the amount the provider charges and the price the insurance company sets, after the patient pays any co-pay, co-insurance, or deductible.

Balance billing can occur when a consumer receives health care services from an out-of-network provider or an out-of-network facility. In-network providers agree with an insurance company to accept the insurance payment in full. In-network providers agree not to balance bill. Out-of-network providers do not have this agreement with the insurance company. Therefore, in the past they sometimes billed the patient for the amount not covered by insurance.

Some health plans, such as Preferred Provider Organization (PPO) or Point of Service (POS) plans, offer some coverage for out-of-network care, but the provider can still balance bill the patient. Other plans offer no coverage for out-of-network providers and leave the financial responsibility entirely on the consumer.

Balance billing is prohibited in both Medicare and Medicaid.

What is surprise billing?

Surprise billing occurs when a patient receives a balance bill after unknowingly receiving care from an out-of-network provider or an out-of-network facility, such as a hospital. This can occur in emergency and non-emergency situations.

Some states have enacted protections for consumers against surprise billing. However, state laws do not apply to self-insured health plans, which account for the majority of people who get coverage through an employer. Now, federal law adds additional protections.

What protections are in place?

A new federal law, the No Surprises Act, protects you from:

• emergency out-of-network medical bills including air ambulances, and
• non-emergency services at an in-network facility.

The federal law applies to plans starting in 2022 and will be enforced by the federal government in Indiana. It applies to self-insured health plans offered by employers as well as health insurance companies.

• A facility (such as a hospital or freestanding emergency room (ER)) or a provider (such as a doctor) may not bill you more than your in-network cost sharing amount for emergency services.

This is true even if the emergency services you received were at an out-of-network facility or performed by an out-of-network provider.

• Under your health plan, you are still responsible for cost sharing amounts that may include copays, coinsurance, and deductibles.
• You are also protected when you receive non-emergency services from out-of-network providers at in-network facilities. An out-of-network provider may not bill you more than your in-network co-pay, co-insurance, or deductible for services performed at an in-network facility.
  • You can still consent in advance to receive care from an out-of-network provider in some situations and agree to pay the provider amounts above your in-network co-pay, co-insurance, or deductible.

What else should I know?

• You must receive notice of your rights under the new law from your health plan and from the facilities and providers that serve you.
• If you think the protections have not been applied correctly, you can file an appeal with your insurance company or request external review of the company’s decision.
• You also can file a complaint with the federal Department of Health and Human Services.

Additional Resources

FAQs with Examples of the No Surprise Act Protections