No Surprises Act

As of January 1, 2022, patients have a right to an estimate of the cost of services they will receive during a procedure or surgery, called a Good Faith Estimate, and more protection from unexpected, or surprise, bills when they receive care from out-of-network providers at in-network facilities. These protections are part of the Consolidated Appropriations Act of 2021 which includes the No Surprises Act.

Good Faith Estimate

In Alaska, in-network providers are required to provide good faith estimates to patients who are uninsured or self-pay, or who are not using their insurance, for the total expected cost of non-emergency healthcare items and services. 

If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate inwriting within 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the healthcare provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask.

If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.

Make sure to save a copy or picture of your Good Faith Estimate and the bill.

To Request an Estimate 

Contact Alaska Urology at 907-563-3103

Disclaimer: All price estimates are estimations only and should not be considered a price quote. Actual charges may vary based on insurance coverage, medical condition, final diagnosis, treatment recommended by your provider, and unknown circumstances. All requests for an estimate will receive a response within 3 to 10 business days.

Your rights and protections against surprise medical bills

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

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 have to 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 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 – like 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.

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 (such as copayments and coinsurance). 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.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You are never required to give up your protection from balance billing. You also are not required to get care out-of-network. You can choose a provider or facility in your plan’s network.

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

You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will payout-of-network providers and facilities directly.

Your health plan generally must:

  • Cover emergency services without requiring you to get approval for services in advance (prior authorization).
  • Cover emergency services by out-of-network providers.
  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
  • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

What the No Surprises Act Doesn’t Cover 

“In-Network Providers” The act doesn’t provide protections against balance billing or unexpected costs when you receive care from a provider who is in-network. 

“Cost-sharing charges” Including copayments, coinsurance, and deductibles, can vary significantly across different insurance plans when the provider or facility is in-network. Consequently, individuals may still incur substantial medical expenses due to the elevated standard in-network cost-sharing charges associated with their specific plan. It is important to note that these types of expenses are not classified as surprise medical bills. 

It is essential for individuals to comprehend which facilities and providers are classified as in-network or out-of-network within their health plan. Services that are pre-scheduled directly with an out-of-network provider are not covered by the legislation, and the provider is permitted to charge patients the full cost of these services.

For instance, an out-of-network provider may impose their full fees if the patient: schedules surgery at an out-of-network hospital, receives primary care from a doctor who is out-of-network, attends a non-emergency office visit with an out-of-network provider, utilizes ground ambulance services, or requires a service that is not included in the plan, such as elective cosmetic surgery.

If you think you’ve been wrongly billed, you may contact the U.S. Department of Health and Human Services’ No Surprises Helpdesk at (800) 985-3059, which is the entity responsible for enforcing the federal balance or surprise billing protection laws.

Review the Model Disclosure Notice (CMS version 2 guidelines) for more information about your rights under federal law.