No Surprises Act
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 for 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.
Billing Disclosures – 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 “balance billing” (sometimes called “surprise 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 healthcare 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 servicesIf 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.
Additionally, Georgia law protects patients from surprise medical bills for: (i) covered
emergency medical services provided by an out of network provider or at an out of network
facility and (ii) covered non-emergency services from an out-of-network provider. This
prohibition on balance billing does not apply if the covered patient chose to receive
non-emergency services from an out-of-network provider and provided oral and written consent.
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 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.
Additionally, Georgia law states that these protections require the patient only to pay their
in-network cost sharing-amount. These protections apply to patients with coverage through a
state healthcare plan, managed care plan or a third party that opts into the prohibition from
balance billing.
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 1-800-985-3059
Visit www.cms.gov/nosurprises/consumers for more information about your rights under
Good Faith estimate
You have the right to receive a “Good Faith Estimate” explaining how much your medical care
will cost.
Under the law, Providers and facilities must give you a good faith estimate if you ask
for one.
● 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.
● Make sure your health care provider gives you a Good Faith Estimate in writing at
least one (1) business day before your medical service or item. You can also 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.