No Surprises Act

As part of the Consolidated Appropriations Act of 2021, on Dec. 27, 2020, the U.S. Congress enacted the No Surprises Act ​ (NSA), which contains many provisions to help protect consumers from surprise bills beginning January 1, 2022. The provisions in the NSA create requirements such as cost-sharing rules, prohibitions on balance billing for certain services, notice and consent requirements, and requirements related to disclosures about balance billing protections. The requirements in the NSA  apply to health care providers and facilities and providers of air ambulance services. These requirements generally apply to items and services provided to individuals enrolled in group health plans or group or individual health insurance coverage, including Federal Employee Health Benefit plans. The NSA's requirements related to the patient-provider dispute resolution process also apply to individuals with no health insurance coverage. 

Some health insurance coverage programs that already had protections against surprise medical billing are exempt from the NSA including Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE. 

If you received a surprise bill that you think is prohibited under the new law, you can: 

• file an appeal with your insurance company
  
  
• file a complaint with OCI
• ​Surprise Medical Bill Complaint Form (Online)
  
• Surprise Medical Bill Complaint Form
  
  
• file a complaint with the federal Department of Health and Human Services ​

Learn more about Protections from Surprise Medical Bills.

Balance billing happens when a health care provider bills a patient after the patient's health insurance company has paid its share of the bill. The balance bill is for the difference between the provider's charge and the price the insurance company sets after the patient has paid any copays, coinsurance, or deductibles.  

Surprise billing happens when a patient gets an unexpected balance bill after they receive care from an out-of-network provider or at an out-of-network facility. Patients often are not aware a provider or facility is out-of-network until they receive the bill. It can happen for both emergency and non-emergency care. For example, a patient may undergo a planned procedure in which the surgeon is in-network with their health plan, but the anesthesiologist is not in-network which may result in a surprise bill. 

Surprise medical billing is a concern for more than 60% of respondents to a National Association of Insurance Commissioners Center for Insurance Policy Research survey. According to the survey, most consumers are afraid that they or a family member will receive a bill that they did not expect for health care services. With the implementation of the No Surprises Act, the Wisconsin Office of the Commissioner of Insurance (OCI) stands ready to assist consumers who receive such bills.   

The NSA protects you from surprise bills for covered emergency out-of-network services, including air ambulance services (but not ground ambulance services), and surprise bills for covered non-emergency services at an in-network facility.  

The law applies to health insurance plans starting January 1, 2022. It applies to the self-insured health plans that employers offer as well as fully-insured plans from health insurance companies. 

An emergency facility and emergency provider may not bill you more than your in-network coinsurance, copay, or deductible for emergency services, even if the facility or provider is out-of-network. It is important to note that if your health plan requires you to pay copays, coinsurance, and/or deductibles for in-network care, you will still be responsible for those costs.  

The new law also protects you when you receive non-emergency services from out-of-network providers at in-network facilities. An out-of-network provider may not bill you more than your in-network copays, coinsurance, or deductibles for covered services performed at an in-network facility. 

You can never be asked to waive your protections and agree to pay more for out-of-network care at an in-network facility for care related to emergency medicine, anesthesiology, pathology, radiology, or neonatology—or for services provided by assistant surgeons, hospitalists, intensivists, or for diagnostic services including radiology and lab services. 

You can agree in advance to be treated by an out-of-network provider in some situations, such as when you choose an out-of-network surgeon knowing the cost will be higher. The provider must give you information in advance about what your share of the costs will be. If you did choose the out-of-network provider knowing the anticipated costs, you will be expected to pay the balance bill as well as your out-of-network coinsurance, deductibles, and copays. 

There is also a federal dispute resolution process available for individuals who are uninsured, in certain circumstances, such as when the actual charges are much higher than the estimated charges.  

Other protections in the new law require insurance companies to keep their provider directories updated. The insurance company also must limit your copays, coinsurance, or deductibles to in-network amounts if you rely on inaccurate information in a provider directory. 

For questions or more information about your rights under the NSA please visit www.cms.gov/nosurprises/consumers ​ or call 1-800-985-3059. Learn more about Protections from Surprise Medical Bills​.

Providers and insurers can find an overview of the provisions required by the No Surprises Act here.  

For health care providers and facilities and providers of air ambulance services, the following requirements are now in effect:  

• Providers and facilities shall not balance bill the patient for out-of-network emergency services 
• Out-of-network providers shall not balance bill for non-emergency services provided at in-network health care facilities unless the patient is provided with adequate notice and consents in writing to be balance billed 
  
• Health care providers and facilities must disclose patient protections against balance billing 
• Out-of-network air ambulance providers may not balance bill for air ambulance services 
• Health care providers and facilities shall provide a good faith cost estimate in advance of scheduled services, or upon request. A good faith estimate template is available here.  
• The Standard Notice and Consent Documents Under the No Surprises Act CMS webpage also includes an estimate template 

A provider or facility must disclose information regarding federal and state balance billing protections and how to report violations. A model disclosure notice can be found here. Providers or facilities must post this information prominently at the location of the facility, post it on a public website, if applicable, and provide it to the enrollee in a timeframe and manner as outlined by regulation. 

Any health care provider or health care facility that has or has had a contractual relationship with a health benefit plan or health insurance issuer must reimburse beneficiaries, enrollees, or participants with interest any amount paid to a provider based on a provider bill th​at was more than the in-network cost-sharing amount. 

Additional information regarding the NSA requirements for insurers and providers can be found here. ​  
 

NSA Enforcement 

States have primary enforcement authority over the new NSA requirements under the changes to the Public Health Service Act made by the Consolidated Appropriations Act, 2021, with respect to health insurance issuers, health care providers and facilities, and providers of air ambulance services.  

In general, OCI enforces the following NSA provisions: 

• External review as requested by health plan participants and beneficiaries and insurance policy enrollees (sections 2719 (as applied by section 110 of the No Surprises Act)) 
• Section 2746 (other than section 2746(c)) 

• Limitations on out-of-pocket costs for out-of-network emergency services 
• Cost-sharing and out-of-network payment amounts 
• Emergency services and non-emergency services provided by an out-of-network provider at an in-network facility  
• Consumer protections related to price transparency and other NSA information 

• Ending surprise air ambulance bills (section 2799A-2 (other than 2799A-2(b))) 
• Continuity of care (sections 2799A-3 and 2799B-8) 
• Maintenance of price comparison tool (section 2799A-4) 
• Protecting patients and improving the accuracy of provider directory information (sections 2799A-5 and 2799B-9) 
  
• Increasing transparency by removing gag clauses on price and quality information (section 2799A-9 (other than section 2799A-9(a)(4))) 
• Balance billing in cases of emergency services (sections 2799B-1) 
• Balance billing in cases of non-emergency services performed by Nonparticipating providers at certain participating facilities (section 2799B-2) 
• Provider requirements with respect to disclosure on patient protection against balance billing (section 2799B-3) 
• Provision of information upon request for scheduled appointments (section 2799B-6) 

The Centers for Medicare & Medicaid Services (CMS) will directly enforce the following NSA provisions in Wisconsin:

• Independent dispute resolution process (sections 2799A-1(c) and 2799A-2(b)) 
• Air ambulance services (section 2799B-5) 
• Patient-provider dispute resolution (section 2799B-7) 
  
  

Learn more about OCI's approach to NSA enforcement here.

Other Guidance & Technical Resources from CMS 

All of these resources and more can be found at No Surprises Act | CMS ​. 

Independent dispute resolution process 

• Checklist of requirements for group health plans and group and individual health insurance issuers (Download Checklist)​​
  
• Paperwork Reduction Act (PRA) model notices and information collection requirements for the Federal Independent Dispute Resolution Process (Download Model Notices and Information Requirements) ​ 
• Calendar Year 2022 Fee Guidance for the Federal Independent Dispute Resolution Process Under No Surprises (Download Fee Information) 
• Federal Independent Dispute Resolution (IDR) guidance for certified IDR entities (Download Guidance) 

Good faith estimates and the patient-provider dispute resolution process 

• NSA good faith estimate guidance for providers ​ 
  
• Guidance on good faith estimates and the Patient-Provider Dispute Resolution (PPDR) process for people without insurance or who plan to pay for the costs themselves (Download Guidance) 
• Guidance on good faith estimates and the Patient-Provider Dispute Resolution (PPDR) Process for providers and facilities as established in Surprise Billing, Part II; Interim Final Rule with Comment Period (Download Guidance) 
• Guidance for Selected Dispute Resolution (SDR) Entities: Required steps to making a payment determination under the Patient-Provider Dispute Resolution (PPDR) process (Download Guidance) 
• Calendar Year 2022 fee guidance for the Federal Patient-Provider Dispute Resolution (PPDR) process established in Surprise Billing, Part II; Interim Final Rule with Comment Period  (Download Guidance) 

Disclosures, notice and consent 

• Standard notice and consent forms for nonparticipating providers & emergency facilities regarding consumer consent on balance billing protections (Download Surprise Billing Protection Form) 
• Model disclosure notice on patient protections against surprise billing for providers, facilities, health plans and insurers (Download Patient Rights & Protections Against Surprise Medical Bills) 
• Requirements for including federal agency contact information and website URL on certain documents (Download Memo of Requirements for Plans, Providers and Facilities) 

Insurance ID cards 

• Health plans and insurers: preliminary information about insurance ID card criteria is available in the Frequently Asked Questions about the Consolidated Appropriations Act, 2021 Implementation Part 49.