Surprise Medical Bills

No. These requirements generally apply to items and services provided to individuals enrolled in group health plans or group or individual health insurance coverage, and Federal Employees Health Benefit plans. The good faith estimate requirement and the requirements related to the patient-provider dispute resolution process also apply to the uninsured.

These requirements do not apply to beneficiaries or enrollees in federal programs such as Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE. These programs have other protections against high medical bills.

It depends. CMS released a chart that provides a high-level summary to assist in determining whether the federal IDR process or a state law or All-Payer Model Agreement applies for determining the out-of-network rate. Please see the document here.

The No Surprises Act prohibits balance billing in three major scenarios:

1. A person gets covered emergency care from an out-of-network provider or out-of-network emergency facility;
2. A person gets covered non-emergency care from an out-of-network provider as part of a visit to an in-network health care facility; or
3. A person gets covered air ambulance services by an out-of-network air ambulance provider.

However, the good faith estimate requirements are broader, and any state- or locally-licensed health care institution will need to comply. CMS confirmed this in a recent FAQ: “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.”

Note that the No Surprises Act’s prohibitions on balance billing for non-emergency services only apply to covered non-emergency services that are furnished as part of a visit to one of the following in-network health care facilities: hospitals (including critical access hospitals); hospital outpatient departments; or ambulatory surgical centers. Out-of-network providers can’t balance bill for non-emergency items and services that are part of a visit at an in-network health care facility. This includes the following: equipment and devices; imagine services; telemedicine services; lab services; preoperative services and postoperative services. These items or services don’t need to happen physically within the in-network health care facility to be treated as part of a visit (e.g., offsite laboratory services).

To ensure compliance with the No Surprises Act, providers/facilities may need to bill the plan or issuer directly to determine whether No Surprises Act requirements apply, given the terms of an individual’s health plan/coverage and a facility’s participation status.

The No Surprises Act’s ban on balance billing for non-emergency services only apply to plan covered services. If a non-emergency service is not covered under the in-network benefits and terms of coverage under an individual’s health plan, then the No Surprises Act’s rules on balance billing do not apply for these services.

No. The requirement to provide a GFE to an uninsured (or self-pay) individual is not triggered upon scheduling an item or service if the item or service is being scheduled fewer than 3 business days before the date the item or service is expected to be furnished. For example, if an uninsured (or self-pay) individual arrives to schedule same-day laboratory testing services, the laboratory testing provider or facility is not required to provide the individual with a GFE.

The No Surprises Act requires plans and issuers to send an initial payment or notice of denial of payment not later than 30 calendar days after a nonparticipating provider/facility submits a bill related to the items and services that fall within the scope of the surprise billing protections for emergency services, non-emergency services performed by nonparticipating providers related to a visit to a participating facility, and air ambulance services furnished by nonparticipating providers of air ambulance services. The 30-calendar-day period begins on the date the plan or issuer receives the information necessary to decide a claim for payment for such services, commonly known as a “clean claim.” The Departments will generally enforce the applicable provisions of the No Surprises Act in conjunction with states where applicable. Providers, facilities, and providers of air ambulance services with concerns about a plan’s or issuer’s compliance with the 30-calendar-day requirement to send an initial payment or notice of denial of payment may contact the No Surprises Help Desk at 1-800-985-3059 or submit a complaint at https://www.cms.gov/nosurprises/policies-and-resources/providers-submit-a-billing-complaint.

The initial payment should be an amount that the plan or issuer reasonably intends to be payment in full based on the relevant facts and circumstances and as required under the terms of the plan or coverage, prior to the beginning of any open negotiation period or initiation of the Federal IDR process. The initial payment is not required to be equivalent to the QPA (or the QPA less the individual’s cost-sharing amount), but the plan or issuer must include the QPA for each item or service with the initial payment or notice of denial of payment, as well as a statement certifying that the QPA applies for the purposes of the recognized amount, among other required information. A notice of denial of payment means, with respect to an item or service for which benefits subject to the surprise billing protections are provided or covered, a written notice from the plan or issuer to the provider/facility that states that payment for the item or service will not be made by the plan or coverage and explains the reason for denial. For example, a notice of denial of payment could be provided if the item or service is covered but is subject to a deductible greater than the recognized amount. The term “notice of denial of payment” does not include a notice of benefit denial due to an “adverse benefit determination.” There is a significant distinction between an adverse benefit determination, which may be disputed through a plan’s or issuer’s claims and appeals process, and a notice of denial of payment or an initial payment that is less than the billed amount, which may be disputed through open negotiation and, after that, through the Federal IDR process. In general, when adjudication of a claim results in a participant, beneficiary, or enrollee being personally liable for payment to a provider or facility, this determination may be an adverse benefit determination that can be disputed through a plan’s or issuer’s typical claims and appeals process. Conversely, when: (1) the adjudication of a claim results in a decision that does not affect the amount the participant, beneficiary, or enrollee owes; (2) the dispute involves only payment amounts due from the plan or issuer to the provider, facility, or provider of air ambulance services; and (3) the provider, facility, or provider of air ambulance services has no recourse against the participant, beneficiary, or enrollee, the decision is not an adverse benefit determination and the payment dispute may be resolved through open negotiation and, if necessary, the Federal IDR process.