Federal No Surprises Act | Health Insurance | No Surprises | Contact Brianna for assistance

Transparency in Health Care

In October 2020, the federal government issued the “transparency in coverage” final rule under the Federal No Surprises Act. The rule provides protection against balance or “surprise” billing under certain circumstances, and phases in new transparency requirements on most group health plans and health insurers. The purpose of the requirements is to enable consumers to make informed healthcare purchasing decisions.

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

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.

Nonparticipating describes providers and facilities that haven’t signed a contract with your health plan. Nonparticipating 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, such as when you have an emergency or schedule a visit at a participating facility but are unexpectedly treated by a nonparticipating provider.

Your rights and protections against Surprises

When you get emergency care or get treated by a nonparticipating provider at a participating hospital or ambulatory surgical center, you are protected from balance or surprise billing.
Services you are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from a nonparticipating provider or facility, the most the provider or facility may bill you is your plan’s in-network out-of-pocket amount, such as copays, coinsurance, and deductibles. 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.

Michigan law also protects you from balance billing and requires that you pay only your in-network cost-sharing amounts for (i) covered emergency services provided by an out-of-network provider at an in-network facility or out-of-network facility; (ii) covered nonemergency services provided by an out-of-network provider at an in-network facility if you do not have the ability or opportunity to choose an in-network provider; and (iii) any healthcare services you receive at an in-network facility from an out-of-network provider within 72 hours of receiving services from that facility’s emergency room.