A New Ban on Surprise Medical Bills Starts This Week

For years, millions of Americans with medical emergencies could receive another nasty surprise: a bill from a doctor they did not choose and who did not accept their insurance. A law that goes into effect Saturday will make many such bills illegal.

The change is the result of bipartisan legislation passed during the Trump administration and fine-tuned by the Biden administration. It is a major new consumer protection, covering nearly all emergency medical services, and most routine care.

“I think this is so pro-consumer, it’s so pro-patient — and its effect will eventually be felt by literally everybody who interacts with a health care system,” said Senator Bill Cassidy, a Republican from Louisiana, who was part of a bipartisan group of lawmakers who wrote the bill. He said he counted the bill as among his top achievements as a lawmaker.

Even with insurance, emergency medical care can still be expensive, and patients with high deductible plans could still face large medical bills. But the law will eliminate the risk that an out-of-network doctor or hospital will send an extra bill. Currently, those bills add up to billions in costs for consumers each year.

“This is such an important consumer victory because it is going to protect consumers from an egregious and pervasive billing practice that has just grown over the years,” said Patricia Kelmar, the health care campaigns director at the consumer group U.S. PIRG.

Behind the scenes, medical providers are still fighting with regulators over how they will be paid when they provide out-of-network care. But those disputes will not interfere with the law’s key consumer protections.

What does the law mean if I go to the emergency room?

If you are having a medical emergency and go to an urgent care center or emergency room, you can’t be charged more than the cost sharing you are accustomed to for in-network services. This is where the law’s protections are the simplest and the most clear for people with health insurance.

You will still be responsible for things like a deductible or a co-payment. But once patients make that normal payment, they should expect no more bills.

“We shouldn’t have to depend on people knowing minutia about insurance regulation in order for them to get care or not be unfairly billed,” said Anthony Wright, the executive director of Health Access California, a patient group that supported the federal law and that fought for a law that banned surprise bills in California starting in 2017.

Several studies found that around 20 percent of U.S. patients who had emergency care were treated by someone outside of their insurance network, including emergency room doctors, radiologists or laboratories. Any of those providers could send patients an extra bill after the fact, and some medical groups did so routinely. Such bills are now illegal.

There is one important exception.

What does the law mean if I need an ambulance?

The new law does not prevent ambulance companies from billing you directly for their services if they travel on roads. It does offer protections against surprise bills from air ambulances.

Ground ambulances were left out of the recent legislation because legislators determined they would need a different regulatory approach. Congress established a commission to study the issue and may consider reforms.

Eleven states prevent ambulances from sending out-of-network medical bills. Patients who live in the other states are quite likely to get a bill in the mail if they require an ambulance. Research shows as many as half of people who need an ambulance receive such a bill, though the amount is not always large.

What does the law mean for routine hospital procedures?

For scheduled services, like knee operations, C-sections or colonoscopies, it’s important you choose a facility and a main doctor that is in your insurance plan’s network. If you do that, the law bars anyone else who treats you from sending you a surprise bill. This also addresses a large problem. Surprise bills from anesthesiologists, radiologists, pathologists, assistant surgeons and laboratories were common before.

If, for some reason, you are having such a service and you really want an out-of-network doctor to be part of your care, that doctor typically needs to notify you at least three days before your procedure, and offer a “good faith estimate” of how much you will be charged. If you sign a form agreeing to pay extra, you could get additional bills. But the hospital or clinic can’t force you to sign such a form as a condition of your care, and the form should include other choices of doctors who will accept your insurance.

“People should really, really think carefully before they sign that form, because they will waive all of their protections,” Ms. Kelmar said. She recommended that patients skip right to the part of the form that lists covered alternatives.

Does this mean I will never be surprised by a medical bill?

No. When health policy experts discuss “surprise bills,” they are talking about a specific thing: extra charges from a medical provider whom patients didn’t choose. But there are still many parts of the U.S. health care system that remain perplexing.

If you have an insurance plan with a high deductible, or have a kind of cost-sharing known as “coinsurance” in which you have to pay a percentage of your medical charges, you could still get a big bill in the mail after any medical care. The government is taking steps to make the costs of medical care more transparent. But it is still not always obvious what medical care will cost in advance, and what insurance plans will cover. It is always worth understanding how your insurance benefit works so that you have a general sense of how much you could be asked to pay beyond your premium.

If you are going to a doctor for something that’s not an emergency, it is also still important to confirm that the doctor is part of your health insurer’s network. Visits to doctors who are out of network could result in extra bills. Mr. Wright recommends asking doctors whether they are “in network” and not whether they simply “accept my insurance.” That’s because some doctors who are out of network will accept insurance payments but still bill patients for additional fees.

What about lawsuits over the law?

Doctor and hospital groups have brought lawsuits challenging a part of the surprise billing law. But even if those lawsuits are successful, there will be little immediate impact on bills. (It is possible they will eventually cause insurance premiums to rise.)

The lawsuits relate to what happens after an out-of-network doctor treats a patient. The new law sets up an arbitration system for the provider and the health insurer to determine a fair payment. In the lawsuits, the medical providers say the regulations for that process are not consistent with the wording of the law and may cause their payments to fall. If they win, they want some of the instructions for the arbiter to be deleted, but they do not seek the ability to send surprise bills.