As part of a federal spending bill (The Consolidated Appropriations Act, 2021) new requirements were put in place to protect people from what are called “surprise medical bills”. Although complex we are providing some basics here and have attached links for more detailed information about surprise medical bills.
What are “surprise medical bills”?
Sometimes when people go to the doctor and insurance covers the visit, they get a bill later. This can happen because of something called “balance billing”.
What is “balance billing”?
Balance billing is when a medical provider bills you for the rest of a charge after your insurance company has paid their limit. These bills are called “surprise medical bills” because the person thought everything was paid by the insurance company.
Things to note:
- Balance billing is different from a deductible, co-pay and co-insurance.
- A deductible is the amount a patient needs to pay out-of-pocket before a health insurance plan starts to pay.
- Co-pays are set amounts the patients pays toward medical care per visit.
- Co-insurance is the amount a person pays after their deductible is met.
Medicaid and Medicare
Balance billing is currently not allowed for people who have Medicaid or Medicare.
Insurance can be complicated. If you believe you might have received a bill because of “balance billing” here are steps you can take:
- look at your medical policy to verify coverage, deductible amounts, co-pay amounts and co-insurance
- if you have difficulty doing this, call your insurance carrier and ask questions about coverage, deductibles, co-pays and co-insurance
- contact the physician/medical provider with your questions about medical bills you have received for an explanation of why you have received the bill
Thirty-three (33) states have taken steps to protect patients from balance billing. Click the link for a map of states and the level of protections in place for that state.
https://www.commonwealthfund.org/publications/maps-and-interactives/2021/feb/state-balance-billing-protections
Click this link for more questions and answers about no surprise billing rules: Frequently asked questions for providers about the No Surprises rules. (PDF)
If you would like more information or help about the new requirements, you can contact: provider_enforcement@cms.hhs.gov.
Additional Information:
The rules don’t apply to people with coverage through programs like Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE. Each of these programs already has other protections against surprise medical bills. The protections also don’t apply to individuals enrolled in short-term limited duration insurance, excepted benefits (such as stand-alone dental or vision-only coverage), or retiree-only plans.
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