One persistent concern in healthcare has been the risk of unexpected medical bills, which can strain individuals’ finances. However, the No Surprises Act offers a measure of protection for those covered under group or individual health plans.

Understanding the Scope of the No Surprises Act

The No Surprises Act addresses a range of situations to shield individuals from sudden and potentially burdensome medical bills. It covers emergency care and non-emergency services obtained from out-of-network providers at in-network facilities and out-of-network air ambulances. The aim is to establish fair mechanisms for resolving payment disputes between insurance plans and healthcare providers.

Protections Extended to Insured Individuals

The No Surprises Act offers several protections for individuals covered by employer-based insurance, Health Insurance Marketplace plans, or private insurance, including:

• Prevention of most surprise bills for emergency services.
• Limitation of out-of-pocket expenses to in-network cost-sharing levels for emergencies and specific non-emergency procedures.
• Regulation of charges for additional services by out-of-network providers at in-network facilities.
• Mandated transparency in billing practices, including clear communication and consent before extra charges are applied.

Safeguards for Uninsured Individuals or Self-Payers

The No Surprises Act provides protections even for those without insurance coverage or those choosing to pay for their healthcare expenses out-of-pocket. Individuals in such circumstances typically receive cost estimates before treatment, enabling them to make informed decisions about their healthcare expenditures.

Challenging Excessive Bills

In cases where individuals receive bills exceeding the estimated costs by at least $400, the No Surprises Act allows for dispute resolution within a 120-day timeframe. This provision addresses discrepancies with the goal of ensuring fair billing practices.

Existing Protections and Collaboration with State Laws

Specific segments of the population, including beneficiaries of Medicare, Medicaid, TRICARE, Indian Health Services, and Veterans Health Administration coverage, already have protection from surprise bills under their respective programs. Additionally, the No Surprises Act complements state laws on surprise billing, ensuring individuals benefit from the most favorable protections available, whether at the federal or state level.

Partnering with Pierce Group Benefits

Staying informed about the provisions of the No Surprises Act can empower individuals to make informed decisions about their healthcare coverage and navigate potential billing challenges more confidently. For comprehensive healthcare resources and guidance, speak with your Pierce Group Benefits Account Executive or get in touch with a PGB Representative at partnership@piercegroupbenefits.com.