The No Surprises Act

WHAT: In 2020, Congress passed the No Surprises Act (NSA), a new law that protects patients from surprise medical bills and requires health plans and providers to make prices more transparent to the general public.

IN BRIEF: Insured patients may not be asked to pay more than they do for their health plan’s in-network providers for emergency services and many non-emergency services. Even if the clinicians that provided treatment do not contract with an insured’s health plan, they may not send a medical bill to a patient for any amount beyond the patient’s expected out-of-pocket expenses. Multiple new processes are required of plans and providers to allow patients to know how much services will cost before treatment is provided.

WHEN: Effective January 1, 2022.

Balance Billing: Patients only pay their in-network cost-sharing rate when they receive emergency care, or when they are unknowingly treated by an out-of-network provider at an in-network facility. Patients may waive their balance billing protections, with some exceptions.
Transparency Provisions: Within 1-3 days before patients receive a service –

1. Providers must provide an itemized good faith estimate (GFE) of expected charges to uninsured and self-paying patients.
2. Plans must provide an advanced explanation of benefits (AEOB) that includes a provider’s GFE, expected patient expenses, and whether coverage is subject to a review of medical necessity.

The NSA also establishes two processes for payment dispute resolution:

1. Patient-Provider Dispute Resolution (PPDR): Uninsured and self-paying patients can request an independent review of their responsibility to pay if their bill is $400 more than the GFE.
2. Independent Dispute Resolution (IDR): Plans and out-of-network providers must submit their final reimbursement offers to a federal arbitration process when they are unable to agree upon a reimbursement rate.