Patient information: No Surprises Act

Smile 1 Dental Group — Suwanee, Georgia

Your rights against surprise billing (No Surprises Act)

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other healthcare provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, or deductible. You may have additional costs or be responsible for the full bill if you see a provider or visit a healthcare facility that is not in your health plan’s network.

“Out-of-network” means providers and facilities that have not signed a contract with your health plan. In some cases, out-of-network providers may 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 often higher than in-network costs and may not count toward your deductible or annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you cannot control who is involved in your care—such as during an emergency or when you receive treatment at an in-network facility but are unexpectedly treated by an out-of-network provider.

Your rights and protections against surprise medical bills

Under federal law, you are protected from balance billing for certain services:

Emergency services

If you have an emergency medical condition and receive emergency services from an out-of-network provider or facility, the most you can be billed is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You cannot be balance billed for these emergency services unless you give written consent after you are stabilized.

Certain services at in-network facilities

When you receive care at an in-network hospital or ambulatory surgical center, some providers involved in your care may be out-of-network. In these cases, you are only responsible for your in-network cost-sharing amount. This includes services such as emergency medicine, anesthesia, pathology, radiology, laboratory services, neonatology, assistant surgeon services, hospitalist care, and intensivist care.

These providers cannot balance bill you and may not ask you to give up your protections, except in limited situations where you provide written consent.

Additional protections

When balance billing is not allowed, you also have the following protections:

• You are only responsible for your share of the cost (copayments, coinsurance, and deductibles) as if the provider were in-network.
• Your health plan must cover emergency services without requiring prior authorization.
• Your health plan must base your cost-sharing on in-network rates.
• Any payments you make count toward your in-network deductible and out-of-pocket maximum.

State laws

Some states have additional protections beyond federal law. These protections may vary depending on where you receive care and your specific health plan.

If you believe you’ve been wrongly billed

If you think you’ve been billed incorrectly, you can contact the No Surprises Help Desk at 1-800-985-3059 or visit CMS No Surprises information for consumers Opens in a new tab for more information about your rights under federal law.

Important notice

This communication is not a bill. You are not responsible for any payment until you receive information from your health plan regarding your in-network cost-sharing obligations.

This page summarizes common federal protections for consumers. It is general information only and does not describe every situation or replace your plan documents or advice from your insurer or qualified professionals.