The No Surprises Act (NSA) establishes new federal protections against surprise medical bills effective January 1st, 2022. Surprise medical bills arise when insured consumers inadvertently receive care from out-of-network hospitals, physicians, or other providers they did not choose. Surprise medical bills pose financial burdens on consumers when health plans deny out-of-network claims or apply higher out-of-network cost sharing; consumers also face “balance billing” from out-of-network providers that have not contracted to accept discounted payment rates from their health plan.
The No Surprises Billing Act will protect consumers from surprise medical bills by:
- Requiring private health plans to cover out-of-network claims and apply in-network cost sharing.
- Prohibiting physicians, hospitals and other covered providers from billing patients more than in-network cost sharing amount for surprise medical bills.
- The No Surprises Billing Act also establishes a process for determining the payment amount for surprise, out-of-network medical bills, starting with negotiations between plans and providers and, if negotiations don’t succeed, an independent dispute resolution process.
More information regarding Your Rights and Protections Against Surprise Medical Bills, See Attachment A
Beginning January 1, 2022, Valley ENT, PC facilities and providers will provide a good-faith estimate of expected charges to uninsured consumers, or to insured consumers if they don’t plan to have their health plan help cover the costs (self-paying individuals). The good-faith estimate will be provided after a patient has scheduled an item or service, or upon their request. It should include expected charges for the primary item or service they, and any other items or services that are provided as part of the same scheduled experience.
Valley ENT, PC will:
- Provide the good-faith estimate within certain timeframes.
- Offer an itemized list of each item or service, grouped by the provider or facility offering care.
- Explain the good-faith estimate to the patient over the phone or in-person if the patient requests it, and then follow up with a paper or electronic estimate.
- Provide the good-faith estimate in a way that’s accessible to our patients.
More information regarding your right to receive a Good Faith Estimate, See Attachment B
Your Rights and Protections Against Surprise Medical Bills
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
Emergency services
If you have an emergency medical condition and get emergency services from an out of network provider or facility, the most the provider or facility may bill you is your plan’s in network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have the following protections:
- You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
- Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (prior authorization).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact the Arizona Department of Insurance at (602) 364-3100. Visit https://www.cms.gov/nosurprises or https://www.difi.az.gov for more information about your rights under federal and state law.
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
- You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
- Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your scheduled medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
- If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
- Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers or call 1-800-985-3059.