The No Surprises Act (NSA) is a federal law under the Consolidated Appropriations Act of 2021, effective January 1, 2022, that gives protections to patients from surprise billing.  Patient Fairness widely considers No Surprises Act provisions when assessing potential reasons to dispute a medical bill.  The NSA includes these requirements.


Good Faith Estimate – Uninsured & Insured Patients

Providers must issue to a patient in advance of services a Good Faith Estimate (GFE) of the expected services and associated costs.
  • The GFE must be in writing or electronic format.



  • The GFE must be in a clear and understandable manner. 


  • The provider must issue the GFE in the following timeframes:
How Far Services Scheduled in Advance Time to Issue GFE
< 3 days prior to services GFE not required
3 – 9 days prior to services Within 1 day after scheduling
Within 3 days after scheduling Within 3 days after scheduling
  • The GFE must include a disclaimer that the information is only an estimate of reasonably expected charges and that actual charges may differ.



  • Uninsured and Self-Pay Patients

The No Surprises Act requires providers to issue GFE directly to uninsured and self-pay patients. 

 

In 2022, HHS began enforcing the requirement to issue a Good Faith Estimate to uninsured patients.

 

  • Insured Patients – Delayed Enforcement

The No Surprises Act requires providers to issue GFEs to the insurance plan for insured patients. 

 

As of Q3 2024, the federal Department of Health and Human Services (HHS) has delayed enforcement of the requirement to issue a Good Faith Estimate to the insurance plan for insured patients.

 

 

Protections From Surprise Billing – Insured Patients

The No Surprises Act protects patients from surprise billing in the following situations (“NSA Protected Circumstances”):

 

  1. Emergency services and post-stabilization services, except for ground ambulance services.
  2. Services rendered by a non-participating network provider while the patient was visiting a participating network hospital or other facility.
  3. Air ambulance services.

 

The patient protections for NSA Protected Circumstances include:

 

  • Providers are prohibited from billing insured patients for out-of-network costs not covered by insurance benefits. Provider may only bill and collect any patient payment responsibilities under in-network insurance benefits.
  • Insurance plans must apply in-network insurance benefit levels and patient payment responsibilities.

 

Because they distinguish between in-network and out-of-network insurance benefit levels, NSA protections from balance billing in NSA Protected Circumstances apply to insured patients only.

 

The following services are covered under NSA Protected Circumstance #3, services rendered by a non-participating network provider while visiting a participating network facility:

Emergency medicine Anesthesiology Neonatology
Pathology Radiology
Diagnostic services, including radiology and laboratory services. Items and services provided by assistant surgeons, hospitalists, intensivists. Items and services provided by a nonparticipating provider if there is no participating provider who can furnish the item or service at that facility.

Waiving Rights and Protections

In limited situations, the No Surprises Act allows some out-of-network providers and facilities to seek written consent from individuals to voluntarily waive protection against balance billing for 1) post-stabilization services and 2) non-ancillary, non-emergency services. These are referred to as notice and consent exceptions.

 

Providers must follow strict requirements for the process and timing of obtaining consent from consumers. This includes the requirement for providers to use the Standard Notice and Consent documents provided by the Centers for Medicare & Medicaid Services to secure consumer consent to waive No Surprises Act balance billing protections.

 

Use of the notice and consent exception is only allowed for post-stabilization services (following emergency services) if all the following requirements are met:

  • An individual is stable enough to travel using non-medical or non-emergency medical transport to an available in-network provider/facility located within a reasonable travel distance given the individual’s medical condition;
  • The individual or their authorized representative is in a condition where they can receive information and provide informed consent;
  • The provider or facility provides written notice and obtains written consent from the individual to waive balance billing protections under the No Surprises Act, in compliance with all related statutory and regulatory requirements; and
  • The provider or facility complies with applicable state laws.

 

Use of the notice and consent exception is only allowed for non-emergency services if all the following requirements are met:

  • The items or services do not meet the definition of ancillary services;
  • The items or services are not furnished as a result of unforeseen, urgent medical needs that arise at the time an item or service is furnished;
  • Another in-network provider can deliver the items or services at the in-network health care facility; and
  • The provider gives written notice and gets written consent from the individual to waive the balance billing protections under the No Surprises Act, in compliance with all related statutory and regulatory requirements.

 

Before a consumer waives their balance billing and cost-sharing protections, the provider or facility must provide the individual with a good faith estimate of expected charges for the items and services that are reasonably expected to be provided.

 


Additional Information on the No Surprises Act

No Surprises Act - Overview of Key Consumer Protections

 

The No Surprises Act protects people from unexpected medical bills

 

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