No Surprises Act

Beginning January 1, 2022, patients have a right to an estimate of the cost of services they will receive during a procedure or surgery, called a Good Faith Estimate, and more protection from unexpected, or surprise, bills when they receive care from out-of-network providers at in-network facilities. These protections are part of the Consolidated Appropriations Act of 2021 which includes the No Surprises Act.

You have the right to receive a “Good Faith Estimate” explaining how much your health care will cost.

Under the law, health care providers need to give patients who don’t have certain types of health care coverage or who are not using certain types of health care coverage an estimate of their bill for health care items and services before those items or services are provided.

When you see a doctor or other health care 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 health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. 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.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care – like when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

When you are treated by an out-of-network provider at an ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

When you get services from an ambulatory surgical center, certain providers may be out-of-network. In such cases, the most providers may bill you is your plan’s in-network cost-sharing amount. This applies to including, but not limited to anesthesia and pathology 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, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You may be entitled to additional protections under Florida law. See below for details.

 You are never required to give up your protection from balance billing. You also are not required to get care out-of-network. You can choose a provider or facility in your plan’s network.

• 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:
  • 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 out-of-network services toward your deductible and out-of-pocket limit.

 If you think you’ve been wrongly billed, you may contact the U.S. Department of Health and Human Services’ No Surprises Helpdesk at 1-800-985-3059, which is the entity responsible for enforcing the federal balance or surprise billing protection laws. Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf and follow CMS version 2 guidelines for more information about your rights under federal law.

If you are covered under certain types of health plans, including health management organizations (HMOs), preferred provider organizations (PPOs), and exclusive provider plans (EPOs), you may be entitled to additional protections against balance billing under Florida law.

Contact the Florida Office of Insurance Regulation at 850.413.3140 or visit the https://www.floir.com/ for more information about your rights under Florida law.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.