Effective January 1, 2022, the federal No Surprises Act provides protections for certain unexpected medical bills consumers may have received from medical providers. The Department of Insurance is able to help Idahoans determine if No Surprises Act protections apply, regardless of whether they have health insurance. To discuss your specific situation, please call Consumer Affairs at (208) 334-4250.
Below is information regarding how consumers can appeal decisions of health insurance companies or health care providers if they believe those decisions are in violation of the No Surprises Act‘s consumer protections.
There are limitations to these protections:
- These new protections generally do not apply to a vision- or dental-only plan and ground ambulance services.
- These new rules don’t apply to: Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE. These health insurance coverage programs already have protections against high medical bills and against surprise medical billing.
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.
The items or services provided must be covered by the person’s health plan or insurance. Cost sharing requirements (i.e., deductible, copayments, coinsurance) would still apply.
How are insured consumers protected in a non-emergency situation?
The No Surprises Act provides protections when a consumer is being treated at an in-network health care 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.
Under certain circumstances, the No Surprises Act may limit the amount of out-of-network charges the consumer is responsible for paying.
The items or services provided must be covered by the person’s health plan or insurance. Cost sharing requirements (i.e., deductible, copayments, coinsurance) would still apply.
How are uninsured consumers protected?
If the consumer does not have health insurance, the health care provider must provide a written “good faith estimate” of reasonably expected charges if you request one or schedule services at least three (3) business days in advance.
If a consumer does not plan to submit a claim to their health plan or insurance company (self-pay), a consumer can request a “good faith estimate” from the healthcare provider when services are scheduled in advance.
The No Surprises Act provides protections if bills are $400 or more over a written “good faith estimate” received prior to scheduled services. Consumers can request help through the CMS Patient Provider Dispute Resolution Process within 120 days of receiving a bill $400 or more over a written “good faith estimate.”
To determine if the No Surprises Act applies to your specific situation, contact Consumer Affairs at (208) 334-4250.