May 5, 2022 5 min read

Federal legislation that took effect on Jan. 1 now protects many Americans from receiving surprise medical bills.

The “No Surprises Act” took effect at the start of the year as a way to help prevent situations like that of a patient from State College who was billed over $2,000 for blood tests that were taken at an in-network hospital by an in-network doctor but sent for analysis at an out-of-network laboratory.

Another consumer from Lancaster had surgery at an in-network hospital performed by an in-network surgeon, but an out-of-network anesthesiologist participated in the procedure, which resulted in a $1,300 bill.

A consumer from Scranton had a baby at an in-network hospital delivered by an in-network doctor but complications led the baby to be seen by an out-of-network neonatologist, resulting in a surprise $750 bill.

Those real-life examples of surprise bills are on record in complaints filed with the Pennsylvania Insurance Department.

“One in 3 Pennsylvanians receive surprise medical bills each year, many while seeking emergency care, and most of them don’t know where to turn for help,” says Antoinette Kraus, executive director of the Pennsylvania Health Access Network.

“The No Surprises Act is a game-changer that will allow patients to focus on their care rather than worrying about unexpected bills, even when they did everything right and sought in-network care.”

What is it?

The Consolidated Appropriations Act of 2021 was passed in late December 2020 and contains many provisions to help protect consumers from surprise bills, including the No Surprises Act, which took effect this year. Consumers now 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 regardless of whether a provider or facility is in-network. That means fewer headaches when trying to coordinate care from your doctors or a hospital and weighing costs depending on whether they are part of your insurance provider’s network.

Previously, if consumers had health coverage and received care from an out-of-network provider, their health plan usually wouldn’t cover the entire out-of-network cost. This left many patients with higher costs than if they’d been seen by an in-network provider. This most often happens in an emergency situation where you might not be able to choose who gives you medical care.

Even if you go to an in-network hospital, you might get care from out-of-network providers at that facility. That’s when the “surprise” bills appear from out-of-network providers billing you for the difference between their charges and the amount your insurance is willing to pay them.

The No Surprises Act protects patients from surprise bills by requiring that emergency services are billed as in-network, without needing prior approval. Also, certain non-emergency services you receive at an in-network facility but that are performed by out-of-network ancillary providers will also be covered as in-network. In both situations, patients will be responsible for no more than their in-network cost-sharing (like a deductible or co-pay) for the service.

The legislation also bans other out-of-network charges and surprise billing by making health-care providers give patients a plain-language notice explaining that patient consent is required to get care on an out-of-network basis before that provider can bill the consumer.

Help for Pennsylvanians

More help with navigating medical bills comes from an executive order signed by Pennsylvania Gov. Tom Wolf. It establishes a way for state residents to resolve bill disputes and get questions answered through the Pennsylvania Insurance Department. The order designates the Pennsylvania Insurance Department as the lead agency to coordinate implementation of the No Surprises Act in the commonwealth. Now, if you receive a surprise medical bill, you can contact the Insurance Department to file a complaint and also seek assistance from your health insurance.

The No Surprises Act protects consumers with coverage through their employer, Pennie (Pennsylvania’s state-based Marketplace), or through an individual plan. It does not apply to consumers with Medicare, Medicaid, CHIP or Tricare, since those programs already have existing balance billing protections. It also does not apply to patients with short-term or other limited benefit coverage. However, those consumers and uninsured individuals will now be able to get an estimate of medical charges before receiving care, and the law creates a process to challenge any bill that is at least $400 higher than the estimate.

If you have questions or need more information on the No Surprises Act or surprise bills, contact the Pennsylvania Insurance Department at 1-877-881-6388 or visit www.insurance.pa.gov/nosurprises. You can also contact the No Surprises Help Desk (NSHD) at 1-800-985-3059 or visit https://www.cms.gov/nosurprises for more information on protections under the act.