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No Surprises Act and FSBP Protect You from Surprise Medical Billing

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No Surprises Act and FSBP Protect You from Surprise Medical Billing

The new No Surprises Act, part of the Consolidated Appropriations Act, 2021, provides protection against surprise medical billing by making health plan participant rights easily accessible through Explanation of Benefits (EOB) and publicly accessible websites.  

Surprise medical billing or “balanced billing” generally occurs when a plan participant receives emergency care and therefore cannot control who attends to them. As a result, care may be provided by an out-of-network doctor at a participating hospital or ambulatory surgical center in the Plan’s network. When this happens, the provider may bill you for the difference between what your plan agreed to pay and the full amount charged for a service. In these instances, the Foreign Service Benefit Plan wants to ensure you are aware of your rights and responsibilities. 

 

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, such as a copayment, coinsurance and/or a deductible. You may have other costs or must 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” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be allowed 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. Examples are 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.  

 

The No Surprises Act provides protection under the following circumstances:

  • Emergency services  

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount. This includes copayments, deductibles and coinsurance. You cannot be balance billed for these emergency services. This includes services you may get after you’re in stable condition. The exception is if you give written consent and give up your protections not to be balanced billed for these post-stabilization services. 

  • Certain services performed by an out of network provider at an in-network hospital or ambulatory surgical center  

When receiving care at an in-network hospital or ambulatory surgical center, certain providers may be out-of-network. If you happen to see one of these providers, the most they may bill you is the Plan’s in-network cost-sharing account. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, and intensivist services.  

If you get other services from any other out-of-network providers at in an in-network hospital or ambulatory surgical center, these out-of-network providers cannot balance bill you, unless you sign a written notice and consent form that allows balance billing and are provided with a good faith estimate of your costs from the hospital or ambulatory surgical center before services are given. If you sign the notice and consent form, you can be balance billed for out-of-network services. You are not required to sign the notice and consent form. You may seek care from an available in-network provider. 

  • Air Ambulance 

When you receive medically necessary air ambulance services from an out-of-network provider, your cost share will be the same amount that you would pay if the service was provided by an in-network provider.  

 

When balance billing isn’t allowed, you also have the following protections:  

  • You are only responsible for paying your share of the cost, such as the copayments, coinsurance, and deductibles, that you would pay if the provider or facility was in-network. Your health plan will pay out-of-network providers and facilities directly.  
  • You’re never required to give up your protections from balance billing. You also don’t have to get care out-of-network. You can choose a provider or facility in your plan’s network. 

 

Standard Notice and Consent Documents 

If you did not sign a consent form given to you by the provider, you should only owe any in-network cost share shown on your EOB. This includes any deductible, coinsurance, or copayment. The provider cannot bill you for more. 

If you did sign a consent form and the provider sends it to us, we may have to rework your claim and you may be responsible for any balance due. 

 

If you believe you’ve been wrongly billed, you may send complaints about potential violations of federal law or state law to: 

  • The U.S. Department of Health & Human Services at: 

 

How to handle services supplied based on inaccurate provider directory information?  

If you relied on inaccurate information from provider directories or website or that was verbally provided, we hold you harmless. In these situations, contact us and we will review the claim. After review, you may be responsible only for your in-network cost share.  

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