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.
Acenda Integrated Health is committed to helping you understand health care costs for your upcoming appointment so you can plan for your care. The federal No Surprises Act went into effect on January 1, 2022. This law was designed to protect individuals served against unexpected or surprise medical bills.
No Surprises Act Overview
- Individuals served are protected from receiving surprise medical bills resulting from out-of-network care for emergency services and for certain scheduled services without prior patient consent.
- Individuals served who do not have insurance or who are not using insurance to pay for care have a right to receive a good faith estimate of their potential bill for health care services when scheduled at least three (3) days in advance.
- Individuals with Medicare, Medicare Advantage, Medicaid, Indian Health Services, VA health care, or TRICARE insurance plans are not covered under the No Surprises Act because these federal insurance programs have existing protections in place to minimize large, unexpected medical bills.
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, like a copayment, coinsurance, or deductible. You may have additional 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” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays 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 plan’s deductible or 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. Surprise medical bills could cost thousands of dollars depending on the procedure or service.
Get a Cost of Care Estimate
- Uninsured and self-pay patients have a right to receive a good faith estimate ahead of scheduled nonemergency health care services. A good faith estimate shows the cost of items and services that are reasonably expected for your health care needs. The estimate is based on information known at the time the estimate was created, and can include costs related to your visit such as medical tests, medications, equipment and hospital fees.
- Health care providers should give you the estimate in writing at least one day before your medical service if your care has been scheduled at least three days in advance. You may also request an estimate at any time.
If you believe you’ve been wrongly billed, you may contact the No Surprises Help Desk at 1-800-985-3059 and/or the New Jersey Department of Health at 1-800-792-9770.
For more information and your rights under the No Surprises Act from the Centers for Medicare and Medicaid Services website, visit www.cms.gov/nosurprises/consumers.
For more information about your rights under New Jersey state laws from the Department of Banking and Insurance website, visit www.state.nj.us/dobi/division_consumers/insurance/outofnetwork.html.
Revised Date: June 2022
