The federal No Surprises Act is slated to be implemented on Jan. 1. It will protect patients from receiving surprise medical bills.
“A patient who has carefully researched and selected an in-network facility and provider or is seeking care because of an emergency should not be stuck with out-of-network costs and billing when they had little or no choice regarding providers that may, in the end, be out-of-network,” said Gov. Tom Wolf. “The Wolf Administration has been committed to protecting consumers from balance billing, and the implementation of the No Surprises Act is a major step toward ending unexpected, upsetting and many times financially devastating medical bills.”
A surprise bill is an unexpected medical bill that a patient receives when they unintentionally obtain healthcare from a provider that is outside their plan’s provider network. Surprise bills can happen in emergency situations, but can also occur in a non-emergency situation, when an out-of-network ancillary provider such as an anesthesiologist or radiologist provides care at an in-network facility.
The No Surprises Act will protect patients from surprise bills by requiring that emergency services are billed as in-network, without needing prior approval, and certain non-emergency services at an in-network facility provided by out-of-network ancillary providers are also covered as in-network. In both situations, patients will be responsible for no more than their in-network cost-sharing (like a deductible or co-pay) for the service.
In addition, the No Surprises Act will ban certain other out-of-network charges and balance billing without advance notice. Healthcare providers and facilities will be required to provide consumers with a plain-language consumer notice explaining that patient consent is required to get care on an out-of-network basis before that provider can bill the consumer.
Wolf also signed an Executive Order designating the Pennsylvania Insurance Department as the lead agency to coordinate implementation of the No Surprises Act in the commonwealth. Patients who receive a surprise medical bill for services provided on or after Jan. 1, 2022, may contact the Insurance Department at insurance.pa.gov/NoSurprises with any questions or to file a complaint. They may also seek assistance from their health plans.
“The Insurance Department has received numerous complaints about surprise bills over the past few years,” said Insurance Commissioner Jessica Altman. “Our medical system is complicated enough. The primary concern following major medical procedures should be recovery, not worry over medical billing. My department stands ready to implement this new legislation and protect consumers who act in good faith.”
“1 in 3 Pennsylvanians receive surprise medical bills each year, many while seeking emergency care, and most of them don’t know where to turn for help,” said Antoinette Kraus, executive director of the Pennsylvania Health Access Network. “The No Surprises Act is a game-changer that will allow patients to focus on their care rather than worrying about unexpected bills, even when they did everything right and sought in-network care. Thanks to Gov. Wolf’s Executive Order announced today, patients in Pennsylvania who continue to receive surprise medical bills will now have a clear way to resolve their bills and get their questions answered through the Pennsylvania Insurance Department.”
“Although the No Surprises Act is a federal law, states will have a role in enforcement,” said Laval Miller-Wilson, executive director of the Pennsylvania Health Law Project. “Pennsylvania’s commitment to this implementation sends an important and inspiring message that all patients, from all walks of life, are important.”
Below are real life examples (with identifying information changed to protect confidentiality) of surprise bills Pennsylvanians have received in the past that were filed as a complaint with the Insurance Department. The No Surprises Act will protect consumers from these and similar situations with its implementation on Jan. 1:
– A consumer from State College was billed over $2,000 for blood tests that were taken at an in-network hospital by an in-network doctor, but sent for analysis at an out-of-network laboratory
– A consumer from Lancaster had surgery at an in-network hospital performed by an in-network surgeon, but an out-of-network anesthesiologist participated in the procedure, which resulted in a $1,300 bill
– A consumer from Scranton had a baby at an in-network hospital delivered by an in-network OB/GYN, but complications led the baby to be seen by an out-of-network neonatologist, resulting in a surprise $750 bill
The No Surprises Act will protect consumers with coverage through their employer, Pennie (Pennsylvania’s state-based Marketplace), or directly through an individual market health insurance company. It does not apply to consumers with Medicare, Medicaid, CHIP or Tricare, as these programs already have their own balance billing protections. It also does not apply surprise medical bill protection to consumers who have short-term or other limited benefit coverage. However, these consumers and uninsured individuals will now be able to get an estimate of the charge for a medical service ahead of receiving care, and the law provides a process to challenge a bill that is substantially in excess of that estimate.
Visit insurance.pa.gov/nosurprises or call 1-877-881-6388 for more information.
