Frequently Asked Questions (FAQs) on No Surprises Act
1. What is No Surprises Act?
- As of January 1, 2022, consumers have new billing protections when getting emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers. Through new rules aimed to protect consumers, excessive out-of-pocket costs are restricted, and emergency services must continue to be covered without any prior authorization, and regardless of whether or not a provider or facility is in-network.
- Previously, if consumers had health coverage and got care from an out-of-network provider, their health plan usually wouldn't cover the entire out-of-network cost. This left many with higher costs than if they’d been seen by an in-network provider. This is especially common in an emergency situation, where consumers might not be able to choose the provider. Even if a consumer goes to an in-network hospital, they might get care from out-of-network providers at that facility.
- In many cases, the out-of-network provider could bill consumers for the difference between the charges the provider billed, and the amount paid by the consumer’s health plan. This is known as balance billing. An unexpected balance bill is called a surprise bill.
2. What are Surprise Medical Bills?
- Before the No Surprises Act, if you had health insurance and received care from an out-of-network provider or an out-of-network facility, even unknowingly, your health plan may not have covered the entire out-of-network cost. This could have left you with higher costs than if you got care from an in-network provider or facility. In addition to any out-of-network cost sharing you might have owed, the out-of-network provider or facility could bill you for the difference between the billed charge and the amount your health plan paid, unless banned by state law. This is called “balance billing.” An unexpected balance bill from an out-of-network provider is also called a surprise medical bill.
- People with Medicare and Medicaid already enjoy these protections and are not at risk for surprise billing.
3. Who is an uninsured or self-pay individual?
- You are generally considered an uninsured or self-pay individual if you do not have health insurance, or do not plan to use your insurance to pay for a medical item or service. If you are an uninsured or self-pay individual, a provider or facility must give you a “good faith estimate” detailing what you may be charged before you receive the item or service.
4. What is Good Faith Estimate?
- Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.
- The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute(appeal) the bill.
- If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.
- You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.
- You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4months) of the date on the original bill.
- There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
5. Who is a convening provider or convening facility?
- Convening provider or convening facility: It is the provider or facility who schedules an item or service or who receives the initial request for a good faith estimate from an uninsured (or self-pay) individual. A convening provider must provide a good faith estimate to the uninsured individuals, including any item or service that is reasonably expected to be provided in conjunction with a scheduled or requested item or service by another provider or facility.
6. Who is a co-provider or co-facility?
- Co-provider or co-facility: It is a provider or facility other than a convening provider or a convening facility that furnishes items or services that are customarily provided in conjunction with a primary item or service. For instance, if a patient schedules a surgery, the convening provider or facility might include in the good faith estimate the cost of the surgery, and the co-provider or co-facility might include the costs of any labs, tests, or anesthesia that might be used during the operation.
7. Which providers and facilities are required to provide GFEs to uninsured (or self-pay) individuals?
- Generally, all providers and facilities that schedule items or services for an uninsured (or self-pay) individual or receive a request for a GFE from an uninsured (or self-pay) individual must provide such individual with a GFE. No specific specialties, facility types, or sites of service are exempt from this requirement.
- The terms “health care provider (provider)” and “health care facility (facility)” are defined in regulations for purposes of the GFE requirements for uninsured (or self-pay) individuals as:
- “Health care provider (provider)” means a physician or other health care provider who is acting within the scope of practice of that provider’s license or certification under applicable State law, including a provider of air ambulance services;
- “Health care facility (facility)” means an institution (such as a hospital or hospital outpatient department, critical access hospital, ambulatory surgical center, rural health center, federally qualified health center, laboratory, or imaging center) in any State in which State or applicable local law provides for the licensing of such an institution pursuant to such law or is approved by the agency of such State or locality responsible for licensing such institution as meeting the standards established for such licensing.
- There may be variations in practice patterns, such as whether a specific provider or facility furnishes services to uninsured (or self-pay) individuals, along with the types of items or services provided. There are some items or services that may not be included in a GFE because they are not typically scheduled in advance and not typically the subject of a requested GFE (such as urgent, emergent trauma, or emergency items or services); however, to the extent that such care is scheduled at least 3 days in advance, a provider or facility would be required to provide a GFE.
- For example, individuals will likely not be able to obtain GFEs for emergency air ambulance services, as these are not generally scheduled in advance. However, making these requirements applicable to providers of air ambulance services helps to ensure that individuals can obtain a GFE upon request or at the time of scheduling non-emergency air ambulance services, for which coverage is often not provided by a plan or issuer and thus even individuals with coverage must self-pay.
8. What happens if more than one provider or facility is involved in providing a primary item or service to an uninsured (or self-pay) individual?
- In instances where multiple providers might be responsible for furnishing care in conjunction with a primary item or service, the “convening provider or facility” must provide a GFE to the uninsured (or self-pay) individual, which includes items or services reasonably expected to be furnished by the convening provider or facility, and items or services reasonably expected to be furnished by co-providers or co-facilities.
- The convening provider or facility is the provider or facility that is responsible for scheduling the primary items or services. Other providers or facilities that furnish items or services in conjunction with the primary item or service furnished by the convening provider or facility are considered “co-providers” and “co-facilities.”
- No later than one business day after scheduling the primary item or service or receiving a request for a GFE, the convening provider or facility must contact all co-providers and/or co-facilities that will provide items or services in conjunction with the primary items or services and request GFE information including the expected charges for these items or services expected to be provided by the co-provider or co-facility.
- We understand that it may take time for providers and facilities to develop systems and processes for receiving and providing the required information from co-providers and co-facilities.
- Therefore, for GFEs provided to uninsured (or self-pay) individuals from January 1, 2022 through December 31, 2022, HHS will exercise its enforcement discretion in situations where a GFE provided to an uninsured (or self-pay) individual does not include expected charges from co-providers or co-facilities.
- We note that nothing prohibits a co-provider or co-facility from furnishing the GFE information to the convening provider or facility before December 31, 2022, and nothing would prevent the uninsured (or self-pay) individual from separately requesting a GFE directly from the coprovider or co-facility, in which case the co-provider or co-facility would be required to provide the GFE for such items or services. Otherwise, during this period (January 1, 2022 through December 31, 2022), we encourage convening providers and facilities to include a range of expected changes for items or services expected to be provided and billed by co-providers and co-facilities.
9. Do providers or facilities need to provide GFEs to all individuals, for instance, patients with Medicare or Medicaid?
- Effective January 1, 2022, providers and facilities are required to provide GFEs to uninsured (or self-pay) individuals who schedule items or services or request an estimate. An uninsured individual is one who is not enrolled in a group health plan, or group or individual health insurance coverage, or a Federal health care program, or a Federal Employees Health Benefits (FEHB) program health benefits plan. A self-pay individual is one who is enrolled in but is not seeking to have a claim submitted to their group health plan, health insurance coverage, or FEHB program health benefits plan for the item or service being scheduled or for which a GFE is requested.
- Under the No Surprises Act statute, providers and facilities are generally not required to provide GFEs to individuals insured under Medicare, Medicaid, or other federal health care programs.
10. Do providers or facilities need to provide GFEs to individuals who have insurance but do not seek to have a claim for such item or service submitted to such plan or coverage?
- An uninsured individual is one who is not enrolled in a group health plan, or group or individual health insurance coverage, or a Federal health care program, or a FEHB program health benefits plan. A self-pay individual is one who is enrolled in but is not seeking to have a claim submitted to their group health plan, health insurance coverage, or FEHB program health benefits plan for the item or service being scheduled or for which a GFE is requested. Providers and facilities are required to provide GFEs to uninsured (or self-pay) individuals. When inquiring about whether an individual is enrolled in a plan or coverage, providers and facilities may wish to consider discussing with the individual whether there are situations where the individual expects that the plan or coverage may not provide coverage for certain items or services.
11. Do providers or facilities need to provide GFEs to individuals who have insurance and are seeking to have a claim submitted to their insurance?
- HHS has not yet issued rulemaking related to the provision of GFEs for individuals who are enrolled in a plan or coverage and are seeking to have a claim submitted to their plan or coverage. Until rulemaking to fully implement this requirement to provide such GFE to a plan or coverage is adopted and applicable, HHS will defer enforcement of the requirement that providers and facilities provide GFE information for individuals enrolled in a plan or coverage and who are seeking to submit a claim for scheduled items or services to their plan or coverage.
12. In what forms must the GFE be provided?
- The GFE must be provided in written form either on paper or electronically (for example, electronic transmission of the GFE through the convening provider’s patient portal or electronic mail), pursuant to the uninsured (or self-pay) individual’s requested method of delivery. GFEs provided to uninsured (or self-pay) individuals that are transmitted electronically must be provided in a manner that the uninsured (or self-pay) individual can both save and print, and must be provided and written using clear and understandable language and in a manner calculated to be understood by the average uninsured (or self-pay) individual. If a patient requests that the GFE information is provided in a format that is not paper or electronic delivery, like orally over the phone or in person, the provider/facility may provide the GFE information orally but must follow-up with a written paper or electronic copy in order to meet the regulatory requirements.
13. Why must a GFE be provided in writing to an uninsured (or self-pay) individual?
- A paper or printable electronic copy of the GFE is integral as it is a required input for the patient-provider dispute resolution (PPDR) process that the uninsured (or self-pay) individual can use if the actual billed charges exceed the GFE by at least $400. When initiating the PPDR, the uninsured (or self-pay) individual must submit a copy of the GFE.
14. Do providers or facilities need to factor in financial assistance an uninsured (or self-pay) individual may receive when calculating the expected charges for items or services included in the GFE?
- Yes. The GFE must reflect the expected charges, including any expected discounts or other relevant adjustments that the provider or facility expects to apply to an uninsured (or self-pay) individual’s actual billed charges. For example, certain tax-exempt hospital organizations are required to meet certain Financial Assistance Policy (FAP) requirements; for purposes of this example, any adjustments expected to be applied under the FAP would be factored in and reflected in the amount reported in the GFE.
15. Do providers or facilities need to provide a GFE to uninsured (or self-pay) individuals who have zero financial responsibility?
- Yes. All uninsured (or self-pay) individuals who schedule items or services or request an estimate must be provided a GFE. A GFE is required even if the uninsured (or self-pay) individual has no estimated financial responsibility because the actual billed charges for the items or services is not guaranteed to be $0 and a GFE is required to initiate the patient provider dispute resolution process if actual billed charges are at least $400 greater than the estimate.