Your rights and protections against surprise medical bills under the No Surprises Act
The No Surprises Act protects you from surprise medical bills for emergency services, out-of-network air ambulance services, and certain non-emergency services provided by out-of-network providers at in-network facilities.
When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
Frequently asked questions related to the No Surprises Act
What is balance billing (sometimes referred to as surprise billing)?
When you see a doctor or other healthcare provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a healthcare facility that isn’t in your health plan’s network (out-of-network).
Out-of-network providers and facilities haven’t signed a contract with your health plan and therefore aren’t in your network. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called balance billing. This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
What is surprise billing?
Surprise billing is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
As of January 1, 2022, you are protected from balance or surprise billing for:
If you get emergency services from an out-of-network provider, air ambulance, or facility, the most the provider or facility can bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent to give up your protections not to be balanced billed for these post-stabilization services.1
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities (not listed above), out-of-network providers can’t balance bill you, unless you give written consent1 and give up your protections.
When balance billing isn’t allowed, you also have the following protections:
You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (prior authorization).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward your in-network deductibles and out-of-pocket limits.
If you want more information about your rights or believe you’ve been wrongly billed, Centers for Medicare and Medicaid Services (CMS) can help. Visit the CMS No Surprises webpage or call 800.985.3059.
Additional information about your rights is also available on the Pennsylvania Insurance Department website.
1 You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.