No Surprises Act
NO SURPRISES ACT-OUT OF NETWORK PROVIDERS AND BALANCE BILLING PROHIBITIONS
Beginning January 1, 2022, certain out-of-network charges will be treated as in-network services for purposes of participant cost-sharing, deductibles, and out-of-pocket limits. There should be no balance billing to you for the remaining charged amount on these types of out-of-network services.
For more information, please see the attached Notice, “Your Rights and Protections Against Surprise Medical Bills,” which can be found at here.
Coverage of these benefits and all other benefits are still subject to the remaining provisions of the Plan, including medical necessity.
If you have any questions, you may contact the Fund office at the numbers listed above or via email to email@example.com.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
What services are protected from balance billing?
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, how am I protected?
- You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
- Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (prior authorization).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
What Steps can I take if I believe I've been wrongly billed?
If you think you’ve been wrongly billed, information and resources are available to you.
Get help by phone
You can send complaints about potential violations of federal law or state law to the U.S. Department of Health & Human Services at 1-800-985-3059.
Get help online
You can also visit the Centers for Medicare & Medicaid Services website to learn about federal guidance to end surprise bills and find help from your state agency.
Questions? Contact Us!
Please note, If you are looking to apply for benefits please contact the Fund office.
In order to avoid a delay in responding to your question(s), please do not leave duplicate messages (e.g., via emails, website submissions or voicemails). We will do our best to respond to your message within 24 business hours. Thank you.