Effective January 1, 2022, the federal No Surprises Act provides new protections for certain unexpected or excessive 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 contact Consumer Affairs at (208) 334-4319.
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 exceptions 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.
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 services must be covered under the insurance policy, and 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, the health care provider must provide a “good faith estimate” of the total cost of scheduled services when services are scheduled in advance. This “good faith estimate” must include reasonably expected costs for scheduled services.
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.
For bills that are $400 or more over a “good faith estimate” received prior to scheduled services, the consumer can request help through the CMS Patient Provider Dispute Resolution Process within 120 days of receiving the initial bill. To determine if your specific situation might qualify for the patient provider dispute resolution process, contact Consumer Affairs at (208) 334-4319.