Effective January 1, 2022, the federal No Surprises Act provides new protections for unexpected or excessive medical bills consumers may have received from medical providers. The Department of Insurance is able to help Idahoans understand and utilize these new consumer protections, regardless of whether they have health insurance.
The Department will be posting further information on the No Surprises Act soon, including details on how consumers can appeal decisions of health insurance companies or health care providers if they believe that those decisions are in violation of the No Surprises Act‘s consumer protections.
How are insured consumers protected in an emergency situation?
Prior to this new law, if a consumer received emergency care or air ambulance transportation, the consumer sometimes owed the difference between what the insurance company would have paid and the amount the medical provider charged for the services.
With this new law, under certain circumstances, the consumer will only be responsible for any applicable deductibles, co-pays, or co-insurance as if the consumer received care or treatment from an in-network provider. Any additional payments will be worked out between the insurance company and the medical provider.
How are insured consumers protected in a non-emergency situation?
The new law provides protections when a consumer is being treated at an in-network facility and receives care from an out-of-network provider. For example, when a patient undergoes surgery in an in-network hospital and receives care from an out-of-network anesthesiologist.
Previously, out-of-network providers were able to bill the consumer for amounts not covered by the insurance policy. Under certain circumstances, the new law will limit how much of the out-of-network charges the consumer is responsible for paying. The consumer will still be responsible for deductibles, co-pays, and co-insurance as outlined in the insurance policy.
How are uninsured consumers protected?
If the consumer does not have health insurance or if the consumer plans to self-pay for a scheduled medical procedure, the health care provider must provide a “good faith estimate” of the total cost of services. This “good faith estimate” must include all primary services and any services related to the procedure.
If the billing received is $400 or more over the “good faith estimate,” the consumer can request help through a patient provider dispute resolution process within 120 days of receiving the initial bill.