No Surprises Act – Balance Billing Protections

The No Surprises Act protects patients from large and unexpected surprise bills for out-of-network emergencies and certain non-emergency services provided in in-network health care facilities. Under the No Surprises Act, nonparticipating providers, facilities, and air ambulance providers are prohibited from balance billing individuals.  This means that the nonparticipating provider, facility, or air ambulance provider may not bill an individual for a dollar amount that exceeds the individual’s in-network cost-sharing obligations.  A nonparticipating provider is any physician or other health care provider acting within the scope of their licensure under applicable state law and who does not have a contractual relationship with the health plan or health insurance issuer.

Effective January 1, 2022, a provider must furnish a self-pay patient with the notice and Good Faith Estimate (GFE) prior to all scheduled services or by request if the patient is shopping for care (and not yet at the point of scheduling). This includes, but is not limited to, office visits, therapy, diagnostic tests, infusions, and surgeries.

Find more information about the New York State Out-Of-Network Emergency and Surprise Medical Bill Law by clicking on a link below:

  1. New York State Out-of-Network Emergency and Surprise Medical Bill Law
  2. NYS DFS –Insurance Circular Letter No. 10 (2021)
  3. Dispute a Surprise Medical Bill – New York State
  4. NYS Out-of-Network Emergency and Surprise Medical Bill Assignment of Benefit form
  5. New York State Independent Dispute Resolution (IDR) For Emergency Services and Surprise Bills

Learn more about the CMS No Surprise Act by clicking on a link below:

  1. CMS – No Surprises Act
  2. Right to Receive a Good Faith Estimate of Expected Charges Notice
  3. Good Faith Estimate Template
  4. Good Faith Estimate Timeline
  5. Ineligible for Patient-Provider Dispute Resolution or Additional Information Needed
  6. Patient-Provider Dispute Resolution Form
  7. Selected Dispute Resolution (SDR) Determination Notice to Parties Provided Under the No Surprises Act
  8. Selected Dispute Resolution (SDR) Entity Notification to Health Care Providers and Uninsured (or self-pay) individuals
  9. Patient and Provider Settle on a Payment Settle on a Payment Amount After Initiating Patient-Provider Dispute Resolution