Your Rights and Protections Against Receiving Surprise Medical Bills

What is the No Surprises Act?

The federal government passed a law called the No Surprises Act which went into effect January 1 ,st, 2022. Before the No Surprises Act, if you had health insurance and received care from anout-of-network provider or an out-of-network facility, even unknowingly, your health plan maynot have covered the entire out-of-network cost. This could have left you with higher costs than if you received care from an in-network provider or facility. In addition to any out-of-network cost-sharing you might have owed, the out-of-network provider or facility could bill you for the difference between the billed charge and the amount your health plan paid unless banned by state law. This is called “balance billing.” An unexpected balance bill from an out-of-network

provider is also known as a surprise medical bill.

 

*If you have Medicare, Medicaid, TRICARE, or receive care through the Indian Health

Services or Veterans Health Administration, you are not at risk for surprise medical billing

because New York state already had these protections in place.*

 

How Does the No Surprises Act Help Me?

If you have group insurance or individual insurance, you cannot be charged more than in-

network cost-sharing for these services. Simply stated, you will pay the in-network portion as contracted through your health insurance. For example, if your health insurance states your

office visit copayment is $20 (you can find this information on your insurance card), the provider

can only charge you $20. If you are uninsured, use self-pay, or choose to self-pay rather than using your health insurance, providers are required to provide you with a Good Faith Estimate of how much your service(s) will cost. This information will help you to make an informed decision in choosing a provider or facility.

 

What is the Good Faith Estimate and How Does it Work?

The Good Faith Estimate is geared toward people who are uninsured or self-pay. It’s a

notification of expected charges for scheduled or requested mental health and substance use

services. The notification is an itemized list of services, the fees for each service, and a diagnosis code(s) that are reasonably expected for mental health and substance abuse services. The expected charge for a service is either:

• the cash pay rate or rate established by a provider for an uninsured (or self-pay) patient,

reflecting any discounts for such individuals; or

• the amount the provider would expect to charge if the provider intended to bill a health

care plan directly for such service.


Disclaimer

Uninsured or self-pay individuals may challenge a bill from a provider through a new patient-

provider dispute resolution process if the billed charges substantially exceed the expected

charges in the Good Faith Estimate. “Substantially exceeds” means an amount that is at least

$400 more than the expected charges listed on the GFE for a specific provider.

 

The Good Faith Estimate is based on information known at the time the estimate was created.

The GFE does not include unknown or unexpected complications or special circumstances that

may arise during treatment. Due to unknown variables, the cost of services may fluctuate and

increase your payment. If this happens, federal law allows you to dispute (appeal) the bill.

 

If any information contained in the original estimate changes, the provider is required to give you

a new GFE within 1 business day of your next scheduled visit.

 

If there is a foreseen need to change providers, there is a requirement to notify you in less than

one business day before your next scheduled visit. The replacement provider is required to

uphold the original GFE as their expected charges.

 

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.

You may contact the health care provider or facility listed to let them know the billed charges are

higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

 

You may also start a dispute resolution process with the U.S. Department of Health and Human

Services (HHS). If you choose to use the dispute resolution process, you must start the dispute

process within 120 calendar days (about 4 months) of the date on the original bill.

 

There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you,you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

 

To learn more and get a form to start the process, go to https://www.cms.gov/nosurprises or call

the No Surprises Help Desk at 1-800-985-3059.

 

For questions or more information about your right to a Good Faith Estimate or the dispute

process, visit https://www.cms.gov/nosurprises/consumers/medical-bill-disagreements-if-you-

are-uninsured or call 1-800-985-3059.