PRC No Surprise Act Disclosure Effective January 1, 2022
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 Martketplace(R), or an individual health insurance plan you purchase directly from an insurance company, these new rules will:
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 any exceptions to these protections?
Some health insurance coverage programs alreadyt have protections agains 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.
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 Martketplace(R), 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-netowrk 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 any exceptions to these protections?
Some health insurance coverage programs alreadyt have protections agains 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.
| PRC No Surprise Act (2022) |