Does the No Surprises Act cover Medicare beneficiaries?

The No Surprises Act only covers people enrolled in private large and small group health plans, self-insured health plans, and Federal Employee Health Benefits plans. Some plans bought under the Affordable Care Act (ACA) are also covered.

The No Surprises Act does not cover Medicare plans, including Original Medicare and Medicare Advantage plans. However, it’s not as bad as it sounds since people with Medicare already have all the protections in the law. The No Surprises Act simply extends them to people with private insurance who don’t have Medicare.

What does the “No Surprises Act” do?

The act protects you when you need emergency medical care in three important ways:

1. Requires private insurance plans to apply in-network cost-sharing for out-of-network claims for emergency care.
2. Prohibits providers from billing patients more than the in-network amount for surprise medical bills.
3. Creates a process for plans and providers to resolve disputes about charges and payments.

There is a catch, however. Out-of-network providers can ask you to sign a waiver allowing them to balance bill you for surprise medical charges. If a provider asks you to sign a Notice and Consent to Balance Bill, you waive your right to protections under the No Surprises Act. That means the provider can bill you for the full out-of-network amount and take steps to collect it.

You can’t be asked to sign a waiver for services you need during a medical emergency. The waiver applies to post-stabilization services or care you get once you are no longer in an emergency situation. Once you can safely travel without an ambulance to an in-network provider, the out-of-network provider can ask you to sign a waiver for the care you receive after that point.

Example: John falls off a ladder, hits his head, and hurts his leg. He goes by ambulance to the nearest emergency room, which isn’t in his plan’s provider network. The doctors examine him and order x-rays. It turns out John’s head is fine, but he broke his ankle. He’s medically stable, but an orthopedic doctor needs to see him to treat the broken leg.

The hospital gives John two options. He can either be treated by the orthopedist on call at the hospital, who does not participate with his plan, or his wife can drive him to a participating hospital nearby to be seen by a specialist in his plan’s network.

If John decides to use the non-network doctor to treat his broken leg, he may be asked to sign a waiver. The doctor can legally do this because John is now medically stable and could safely travel to an in-network provider.

Keep in mind, a provider can’t force you to sign a waiver just because they ask. Once you sign, you automatically lose your protections. Talk to the hospital’s patient advocate if you have questions or disagree with anything you are asked to do. They’re there to help you understand your rights and explain your options.

A provider can’t ask you to sign a balance billing waiver for any of the following services:

• Emergency services
• Lab work and x-rays
• Doctor bills for emergency medicine, anesthesiology, radiology, pathology, and neonatology
• Emergency care resulting from a non-emergency service or procedure (a severe allergic reaction to a shot, for example)
• Any services provided by a non-network provider when there is no network provider in the facility and the service is medically necessary  

How do I know if I get a surprise bill covered by the No Surprises Act?

Your doctor or hospital has to identify any bill they send you that’s covered by the No Surprises Act. They also need to send a written one-page notice that explains the act and what to do if you dispute any of the charges.

If your insurance plan pays a surprise medical bill covered by the act, it needs to include that information in the explanation of benefits. The plan also needs to send a written disclosure about how they paid the claim and what to do if you dispute it.

If you get a bill you think should be covered by the No Surprises Act, you can dispute it with your plan. If you’re not happy with the result, you can call the No Surprises Act Help Desk at the Department of Health and Human Services at 1-800-985-3059.

Data from the Kaiser Family Foundation shows that about one in every five emergency room visits results in surprise medical bills.