The No Surprises Act: what it protects and how to use it

Protections if you have insurance

• Emergency care: emergency room visits, and in most cases care after you're stabilized. The hospital, the providers treating you there, and an air ambulance generally can't charge you more than your in-network cost sharing (copay, coinsurance or deductible).
• Non-emergency care at an in-network facility: out-of-network providers who treat you during a visit to an in-network hospital, hospital outpatient department or ambulatory surgical center.
• Air ambulance: covered by the protections.

Not covered: ground ambulance bills generally aren't protected unless your state law says otherwise. The law also doesn't apply to short-term limited duration plans, health care sharing ministries, fixed indemnity plans, or dental-only and vision-only plans. If you have Medicare, Medicaid, TRICARE, VA care or Indian Health Service coverage, CMS points you to a separate action plan finder for your coverage.

The notice and consent form: when you can give up your rights

For some planned care, an out-of-network provider at an in-network facility can ask you to sign a form agreeing to out-of-network charges. Signing means you give up these protections and usually pay more. Signing is your choice.

• Some providers can never ask you to sign: emergency medicine, anesthesiology, pathology, radiology, neonatology, assistant surgeons, hospitalists, intensivists and diagnostic services. Nobody can ask you to sign one for emergency care.
• The form must be given separately from other paperwork, in advance, in your preferred language and format, and the provider must answer your questions.

Good faith estimates if you're uninsured or self-pay

If you don't have insurance, or you tell the provider you won't use it, you generally get a written good faith estimate when you schedule care at least 3 business days ahead, or any time you ask. It lists expected charges, including facility fees. You won't get one during emergency care.

Each estimate covers one provider or facility, so ask every provider involved, such as the surgeon, the anesthesiologist and the facility, for their own.

How to dispute a bill above your estimate

You can use the federal patient-provider dispute process if all of these are true:

• You didn't have or didn't use insurance, and told the provider beforehand.
• You got a good faith estimate at least 3 days before your appointment.
• One provider or facility billed at least $400 more than its estimate.
• Your first bill is dated within the last 120 calendar days.

1. Gather your estimate, your bill and the provider's contact details.
2. Start the dispute online through the CMS No Surprises dispute portal, or by mail or fax. Send copies, not originals.
3. Pay the $25 non-refundable administrative fee; the process doesn't start until it's paid. If you win, the $25 comes off what you owe.
4. An independent reviewer decides the amount you pay. While the dispute is open, the provider can't send the bill to collections or charge late fees.

If you used insurance, you generally can't use this dispute process. Instead, submit a complaint to the Help Desk for a surprise bill, or appeal through your plan if it denied part of a claim.

What to do if you get a surprise bill

1. Compare the bill with your Explanation of Benefits. Check whether the service was an emergency or happened at an in-network facility.
2. Ask the provider and your insurer to reprocess it at in-network cost sharing.
3. Call the No Surprises Help Desk at 1-800-985-3059 (7 days a week, help in 350+ languages) or submit a complaint on cms.gov.
4. For anything else on the bill, see how to negotiate a medical bill.

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