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No Surprises rules protect people from receiving unexpected medical bills

The Consolidated Appropriations Act of 2021 created several new requirements to protect people from receiving surprise medical bills. These new requirements are collectively called the “No Surprises” rules. Patients now have new billing protections when receiving emergency care; certain non-emergency care from out-of-network providers during visits to specified in-network facilities; air ambulance services; and out-of-network providers. These conditions generally apply to items and services provided to patients enrolled in group and individual health insurance plans, as well as federal employees’ health benefits packages. These protections also apply to individuals with health insurance plans obtained through the federal and state-based marketplaces, or directly through an individual health insurance carrier. The new surprise billing requirements and prohibitions include:

  • No balance billing for out-of-network emergency services. 
  • No balance billing for non-emergency services by out-of-network providers during patient visits to certain in-network health care facilities, unless notice and consent requirements are met for certain items and  services. 
  • Providers and healthcare facilities must publicly disclose patient protections against balance billing. 
  • No balance billing for covered air ambulance services by out-of-network air ambulance providers. 
  • In instances where balance billing is prohibited, cost-sharing for insured patients is limited to in-network levels or amounts.  
  • Providers must give a good faith estimate of expected charges to uninsured and self-pay patients of at least three business days before a scheduled service, or upon request.
  • Health plans, issuers, providers and facilities must ensure continuity of care when a provider’s network  status changes in certain circumstances. 
  • Health plans, issuers, providers and facilities must implement certain measures to improve the accuracy of provider directory information.

The rules don’t apply to people with health coverage through programs like Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care or TRICARE. These programs already have protections against surprise medical bills. The safeguards also don’t apply to individuals enrolled in short-term, limited-duration insurance, stand-alone dental or vision-only coverage and retiree-only plans. The uninsured and self-pay individuals are also entitled to a good faith estimate, upon request or scheduling of an item or service, through the No Surprises billing protections.