No Surprises Act
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Effective January 1, 2022, the No Surprises Act, which Congress passed as part of the Consolidated Appropriations Act of 2021, is designed to protect patients from surprise bills for emergency services at out-of-network facilities or out-of-network providers at in-network facilities, holding them liable only for in-network cost-sharing amounts. The No Surprises Act also enables uninsured patients to receive a good faith estimate of the cost of care.
Know Your Rights and Protections Against Surprise Medical Bills
When you receive emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing.
What you need to know about “surprise billing”
“Out of network” is a phrase used in medical insurance to describe when a doctor or facility doesn’t have a contract with your health plan, so they can charge you the full price of services. 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.”
“Surprise billing” is an unexpected balance bill. In many hospitals and surgery centers, you can’t control who is involved in your care– such as an emergency or when you schedule a visit at a known in-network facility but are unexpectedly treated by an out-of-network provider.
When you see a doctor or other health care provider that is in-network, it’s common to owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. These are expected costs and are NOT protected by the No Surprise Act.
What you are protected from through the No Suprise Act
Emergency Services
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, you cannot be billed more than your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You cannot be “balance billed” for these emergency services. This includes services you receive 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.
Additionally, New Mexico protects patients from balance billing when patients receive: (i) emergency services from an out-of-network provider or provided at an out-of-network facility; (ii) covered non-emergency services provided by an out-of-network provider at an in-network facility if the patient did not have the ability or opportunity to choose an in-network provider; and (iii) medically necessary care from an out-of-network provider when an in-network provider is unavailable within a patient’s network.
Certain services at an in-network hospital or ambulatory surgical center
When you receive services from an in-network hospital or ambulatory surgical center, certain providers 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 protection from balance billing. You also aren’t required to receive out-of-network care. You can choose a provider or facility in your plan’s network.
Additionally, New Mexico law states that if a patient chooses to receive non-emergency care from an out-of-network provider, the balance billing protection does not apply. These protections only require patients to pay their in-network cost-sharing amounts. This protection applies to any entity subject to New Mexico’s insurance laws.
The following protections also apply to you:
You are responsible to pay for your share of the cost (such as 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 should:
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.
If you believe you’ve been wrongly billed, you may contact:
The U.S. Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (1-800-633-4227) or visit https://www.cms.gov/nosurprises for more information about your rights under federal law.
The New Mexico Office of Superintendent of Insurance, Managed Care Bureau, by completing an online complaint form at www.OSI.state.nm.us or calling 1-855-4-ASK-OSI.
What you need to know about a Good Faith Estimate
You have the right to receive a “Good Faith Estimate” explaining how much your medical care may cost.
Under the law, healthcare providers need to give patients who don’t have insurance or who are paying out-of-pocket, an estimate of the bill for medical items and services.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
Be proactive! Contact your healthcare provider in advance so they can provide a Good Faith Estimate in writing at least one business day before your medical service or item. You can ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate.
Get More Information
For questions or more information about your right to a Good Faith Estimate, visit cms.gov/nosurprises or call 1-800-MEDICARE (1-800-633-4227).