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The No Surprises Act

I’m going to go out on a limb and say that most Americans have heard the phrase “unexpected medical bill”. It’s also very possible that many of you reading this have had a surprise medical bill. In fact, one out of five Americans have received a surprise medical bill due to an emergency room visit and about as many have received a surprise medical bill due to a non-emergency hospital stay. Nearly two out of three Americans fear unexpected bills and half cannot afford to pay them.

Starting January 1, 2022, The No Surprises Act will have new billing protections when getting emergency care from out-of-network providers at in-network facilities. For example, if a person has emergency surgery, it’s possible that one of the treating physicians will be out of network. It’s very hard to ask who’s in-network when you are unconscious.

How does this impact Medicare beneficiaries? The impact varies depending on if you have Original Medicare (typically paired with a Medicare supplement) or a Medicare Advantage plan.

If you have Original Medicare as your primary coverage, in general, the likelihood of you encountering a surprise medical bill would be low since most providers accept assignments from Medicare. If they accept assignment, they must accept Medicare’s payment. Medicare will then bill your supplement, and the supplement will pay as the secondary according to the plan you have.

In my estimation, the largest impact to Medicare will be with those who have Medicare Advantage plans. This is in large part to Medicare Advantage plans being PPO and HMOs. You could typically navigate this exposure by making sure your providers were in-network, but it’s nearly impossible to do that in an emergency.

To summarize, the No Surprises Act has the greatest impact on Medicare Advantage plan members in the event of an emergency. This should relieve anxieties about unexpected bills, but I encourage you to remain vigilant in your medical care. That said, a surprise bill is not a bill that counts toward your Part B deductible or a bill that was as per your benefit schedule in a Medicare Advantage plan. These are bills that should be anticipated. You have the right to ask your provider how much you should expect to pay for a service.

A bill is also not considered unexpected if the provider has you sign an Advanced Beneficiary Notice prior to your procedure. An ABN is a form issued by a provider in situations where Medicare payment is expected to be denied. When you sign it, you are agreeing to accept financial responsibility. My advice, know what you are signing! Don’t be afraid to ask how much services will cost and if they are covered by Medicare prior to having the service. You are the consumer so do not be intimidated, it’s your right to know how much your care will cost!



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