By Sonya Sellmeyer, Consumer Advocacy Officer for the Iowa Insurance Division

On January 1, 2022, the No Surprises Act began providing health insurance balance billing and surprise billing protections for consumers.  Balance billing occurs when a provider bills the consumer for the difference between the insurance company's allowed amount and the amount billed by the provider.  This amount billed to the consumer is after their applicable deductibles, copays, and coinsurance.  Surprise billing occurs when a consumer unknowingly receives a service or receives services from an out-of-network provider.

The No Surprises Act protects consumers from the following balance and surprise billing situations:

1) Emergency services at an out-of-network provider or facility, including emergency air ambulance services from a nonparticipating provider.  Ground ambulance balance billing protections are not covered by the No Surprises Act.  

2) Post stabilization services after emergency services are received.

3) Non-emergency services received at an in-network facility such as a hospital or surgical center unknowingly by an out-of-network provider such as an anesthesiologist, pathologist, radiologist, neonatologist, or laboratory services; and items and services provided by assistant surgeons, hospitalists, and intensivists.  

Essentially, the No Surprises Act stops out-of-network providers from billing more than an in-network provider in emergency and unknowing situations.  This law applies to consumers with group health plans, group or individual health insurance coverage, and Federal Employees Health Benefits plans. 

Consumer Notice Required. Your insurance carrier and providers must provide you notice of your rights under the No Surprises Act.  If there is a disagreement on a cost-sharing amount, you may only be required to pay the in-network amount while your insurance company and the provider negotiate the bill.  

If you purposefully decide to get care from an out-of-network provider (self-pay), the No Surprises Act requires consumers provide consent to the out-of-network charges.  Consumers must also be provided with a good faith estimate of the costs, whether there are in-network providers at the facility who can do the same service, and a list of the protections the consumer is waiving. 

Uninsured consumers must also be provided a good faith estimate of the cost of the service or procedure and may access the patient-provider dispute resolution process if the consumer receives a final bill that is more than $400 over the good faith estimate.  

Remember, under the No Surprises Act health carriers must cover out-of-network services during an emergency, and when you receive out-of-network services unknowingly at an in-network facility.  The costs will be determined as if the provider was in-network.  If you receive a bill from your provider that you believe is protected by the No Surprises Act, please call the Iowa Insurance Division at 877-955-1212 or file a consumer complaint.   Additional information on the No Surprises Act may be found at the Iowa Insurance Division and CMS websites.