The No Surprises Act, in effect since January 1, 2022, protects people who use most types of private health insurance or don't have or use insurance. The Centers for Medicare & Medicaid Services (CMS) says Medicare, Medicaid, and some other government programs already protect you from some unexpected out-of-network bills on their own. So if you have Medicare, your protection against surprise bills mostly comes from Medicare's billing rules, like assignment and the limiting charge, and from your Medicare Advantage plan's rules.
Does the No Surprises Act apply to people with Medicare?
Generally, its main billing protections are written for people with private health insurance and for people who are uninsured or paying on their own. CMS's "Know your medical bill rights" page says the law protects people who:
- Use most types of private health insurance.
- Don't use health insurance.
- Don't have health insurance.
For people who use Medicare, Medicaid, Indian Health Services, Department of Veterans Affairs (VA) health care, or TRICARE, CMS says those programs "already protect you from some unexpected out-of-network bills." CMS also offers to help people in those programs who have a billing problem.
If you have both Medicare and private coverage, such as an employer plan from a working spouse, ask the No Surprises Help Desk how the rules apply to your situation.
What does the No Surprises Act protect against for people it covers?
For people using most private health insurance, CMS says the law, in most cases, protects against unexpected out-of-network bills from:
- Emergency room visits.
- Non-emergency care at in-network hospitals, hospital outpatient departments, and ambulatory surgical centers.
- Air ambulance services.
For people who don't have or don't use insurance, providers usually must give a good faith estimate of costs, and you may be able to dispute a bill that's at least $400 more than the estimate.
Ground ambulance services generally aren't covered by the law's billing protections, unless a state law says otherwise.
How does Original Medicare protect me from surprise bills?
Original Medicare doesn't have networks. You can see any provider who takes Medicare. Your protection comes from how providers work with Medicare:
- Providers who accept assignment agree to charge you only the Medicare deductible and coinsurance, according to Medicare.gov.
- Non-participating providers can charge more than the Medicare-approved amount, but in many cases no more than 15% above it. That's the limiting charge.
- Providers who opted out of Medicare set their prices through a private contract with you, and Medicare won't pay them except in emergencies.
Your Medicare Summary Notice shows the "Maximum You May Be Billed" for each service. That's the number to check any bill against.
How does Medicare Advantage protect me from surprise bills?
Medicare Advantage plans have networks, so out-of-network care can cost more. Some protections:
- Plan directed care. Medicare.gov says if a plan provider refers you for a covered service or to an out-of-network provider without getting approval first, in most cases you won't have to pay more than the plan's usual cost sharing.
- Yearly out-of-pocket limit. Medicare's "Understanding Medicare Advantage Plans" booklet says plans have a yearly limit on what you pay for covered Part A and Part B services, which may include a separate limit for out-of-network care.
- Appeals. If your plan denies payment, you can appeal within 65 days from the date on the denial notice.
One exception to watch: the booklet notes some Private Fee-for-Service plans allow providers to "balance bill" up to 15% more than the plan pays.