No Surprises Act and Good Faith Estimates 

What is the No Surprises Act for private pay clients?

Beginning January 1, 2022,  Congress enacted and the President signed into law the No Surprises Act, providing new federal consumer protections against surprise medical bills. In the case that you are not enrolled in a health plan or coverage or if you decide not to use your insurance, all providers (individual or a facility) must send your health plan a “Good Faith Estimate” amount of scheduled services, including any expected ancillary services and the expected billing and diagnostic codes for all items and services to be provided.

In other words, under the new law, health care providers need to give patients who don’t have insurance or who are not using their insurance an estimate of the bill for medical items and services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

Make sure to save a copy or picture of your Good Faith Estimate.

What are surprise medical bills?

If you have health insurance and get care from an out-of-network provider or at an out-of-network facility, your health plan may not cover the entire out-of-network cost. This can leave you with higher costs than if you got care from an in-network provider or facility. In the past, in addition to any out-of-network cost sharing you might owe, the out-of-network provider or facility could bill you for the difference between the billed charge and the amount your health plan paid, unless banned by state law. This is called “balance billing.” An unexpected balance bill from an out-of-network provider is also called a surprise medical bill.

What are the new protections if I have health insurance?

If you get health coverage through your employer, the Health Insurance Marketplace®, or an individual health insurance plan you purchase directly from an insurance company, these new rules will:

  • Ban surprise bills for emergency services, even if you get them out-of-network and without approval beforehand (prior authorization).

  • Ban out-of-network cost-sharing (like out-of-network coinsurance or copayments) for all emergency and some non-emergency services. You can’t be charged more than in-network cost-sharing for these services.

  • Ban out-of-network charges and balance bills for supplemental care (like anesthesiology or radiology) by out-of-network providers who work at an in-network facility.

  • Require that health care providers and facilities give you an easy-to-understand notice explaining that getting care out-of-network could be more expensive and options to avoid balance bills. You’re not required to sign this notice or get care out-of-network.

What if I don’t have health insurance or choose to pay for care on my own without using my health insurance?

If you don’t have insurance or you choose to pay for care without using your insurance (also known as “self-paying” for care), these new rules make sure you can get a “good faith estimate” of how much your care will cost, before you get care.

Are there exceptions to these protections?

Some health insurance coverage programs already have protections against high medical bills. You’re already protected against surprise medical billing if you have coverage through Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE.

For more information on the No Surprise Act, you can check the federal government’s official website. More information on similar, state-level legislation in Washington can be found here.