The situation happens all too often: You go to an in-network hospital but receive a surprise medical bill from an out-of-network doctor. However, since Jan. 1, 2022, a new federal law – the No Surprises Act – will protect consumers from many types of these surprise bills.
Surprise billing happens when you get an unexpected bill after you receive care from an out-of-network provider or at an out-of-network facility, such as a hospital. It can happen for both emergency and nonemergency care. Typically, patients don’t know the provider or facility is out of network until they receive the bill.
Surprise medical bills typically are sent by your health care provider for the remaining charges for services you received that are not covered by your insurance (known as balance billing). The new law protects consumers from either of the following situations:
• Emergency services provided out of network, including air ambulance services (but not ground ambulance services)
• Nonemergency services provided by an out-of-network provider at an in-network facility
In an emergency situation, a facility or provider may not bill you more than your in-network co-insurance, co-pays, or deductibles for emergency services as outlined in your plan documents, even if the facility or provider is out of network. However, if your health plan requires you to pay co-insurance, co-pays, or deductibles for in-network care, you are still responsible for those.
In a nonemergency situation, out-of-network providers (such as an anesthesiologist) may not bill you more than your in-network co-insurance, co-pays, or deductibles for covered services performed at an in-network facility without your consent.
If you believe you have received a surprise medical bill from a health care provider that meets either of the above criteria, contact the U.S. Department of Health and Human Services to file a complaint by calling 800-985-3059 (toll-free) or going to https://www.cms.gov/nosurprises/consumers.
If you have received a surprise bill you believe is not allowed under the new law, you can file an appeal with your insurance company, then ask for an external review of the company’s decision after the initial appeal is completed with your plan. You can also contact Oregon’s Division of Financial Regulation to speak with a consumer advocate or file a complaint in any of the following ways:
• Phone: 888-877-4894 (toll-free)
• Email: DFR.InsuranceHelp@dcbs.oregon.gov
The law applies to most health insurance plans, including those offered by an employer. It includes group health plans, health insurance companies for group and individual health coverage, grandfathered health plans, ERISA plans, and self-insured government plans. Medicare and Medicaid have their own protections against balance billing.
The law also has the following protections:
• Health plans and their facilities/providers must send you a notice of your rights under the law.
• Insurance companies must keep their provider directories updated. They must limit co-pays, co-insurance, or deductibles to in-network amounts if you rely on inaccurate information in a provider directory.
• Health care providers must provide a good faith estimate for services to anyone who is uninsured or self-pays (without insurance).
The Division of Financial Regulation is hosting No Surprises Act: Provider Requirements, a Zoom webinar, on Wednesday, Jan. 5, from noon to 1 p.m. PST. In the webinar, staff members from the Centers for Medicare and Medicaid Services will present on provider requirements and answer questions from stakeholders. To view the webinar, go to https://www.zoomgov.com/j/1603031760.
More information about the new law is available at dfr.oregon.gov.