What the No Surprises Act means to you

Unexpected bills can be stressful. Even more so when they are emergency medical bills. Now, if you are on an individual medical plan or on most group health plans, the federal No Surprises Act (NSA) protects you from these unexpected costs by reducing the amount you are billed.

Here’s how it works

Out-of-network providers caring for you at in-network facilities, air ambulance providers and providers of emergency services may only charge you the cost-sharing, such as your deductible and coinsurance, that you would have paid for in-network services. These providers cannot charge you more than this — this is called balance billing is prohibited under the NSA.

This applies to most insured and self-funded group health plans and individual medical plans. It does not apply to short-term medical plans, dental only, vision only, Medicaid, Medicare Supplemental or Medicare Advantage plans.

For Idaho Members

Your Rights and Protections Against Surprise Medical Bills

When you get 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 or balance billing.

What is “surprise billing” (sometimes called “balance 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.

You are protected from balance billing for:

Emergency services

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, you also have the following protections:

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.

If you believe you’ve been wrongly billed, you may contact Idaho Department of Insurance by visiting the department's website at doi.idaho.gov/nosurprises or calling the Consumer Affairs section at 1-208-334-4319 or toll-free in Idaho at 1-800-721-3272.

Visit doi.idaho.gov/nosurprises for more information about your rights under this law.

If you are a provider

Reimbursement to providers and facilities for services subject to the No Surprises Act (NSA) will be based on a calculation called the Qualifying Payment Amount (QPA), made in compliance with the NSA. Moda Health certifies that when the QPA is used it will comply with the NSA and will serve as the recognized amount, which forms the basis for member cost sharing. If a provider is not in agreement with the amount Moda Health pays, the provider may request a 30-day open negotiation of the amount. If the 30-day negotiation period does not result in a determination, in general the provider or facility may initiate the independent dispute resolution process within four (4) days after the end of the open negotiation period. An independent arbitrator will review the dispute and make a binding determination as to what the provider should be paid.

To initiate open negotiation for purposes of determining an amount of payment (including cost sharing) for a service subject to the NSA, contact Moda Health at NoSurprisesActIDR@modahealth.com.