In-network cost sharing for surprise bills will be based on a “recognized amount,” which in most cases will be the median in-network payment amount under the plan for the same or similar services.

The law requires surprise bills must be covered without prior authorization and in-network cost sharing must apply. An advisory committee will be appointed to recommend options for protecting patients against surprise ground ambulance bills. The law requires private health plans to cover surprise medical bills for emergency services, including air ambulance services, as well as out of network provider bills for services rendered at in-network hospitals and facilities. Health plans must cover surprise bills at in-network rates. The law contains key provisions to protect consumers against the cost of surprise medical bills.

This brief summarizes key provisions of the No Surprises Act and issues that could arise during implementation. The new law contains other related provisions, including a requirement for health plans to keep network provider directories up to date. The new law takes effect for health plan years beginning on or after Januand it applies to nearly all private health plans offered by employers (including grandfathered group health plans and the Federal Employees Health Benefits Program), as well as non-group health insurance policies offered through and outside of the marketplace. Surprise medical bills are not a problem today under public programs – Medicare and Medicaid – that prohibit balance billing. 1 Balance billing on surprise medical bills can reach hundreds or even thousands of dollars. Or plans might pay a portion of the bill, but leave the patient liable for balance billing – the difference between the undiscounted fee charged by the out-of-network provider and the amount reimbursed by the private health plan. A health plan that generally doesn’t cover out-of-network care, such as an HMO, might deny a surprise bill entirely. Among privately insured patients, an estimated 1 in 5 emergency claims and 1 in 6 in-network hospitalizations include at least one out-of-network bill. Surprise bills can number in the millions each year. Surprise bills lead the list of affordability concerns for many families 2 in 3 adults say they worry about unexpected medical bills, more than the number worried about affording other health care or household expenses. They also arise in non-emergencies when patients at in-network hospitals or other facilities receive care from ancillary providers (such as anesthesiologists) who are not in-network and whom the patient did not choose. Surprise bills arise in in emergencies – when patients typically have little or no say in where they receive care. The No Surprises Act contains key protections to hold consumers harmless from the cost of unanticipated out-of-network medical bills.

Its enactment followed nearly two years of Congressional debate over competing approaches to the problem that, at times, appeared to be deadlocked. The measure was included in omnibus legislation funding the federal government for fiscal year 2021 and providing stimulus relief for the COVID-19 pandemic. In the closing days of 2020, Congress enacted and the President signed into law the No Surprises Act, providing new federal consumer protections against surprise medical bills.

Medical billings