What is the No Surprises Act?
The No Surprises Act is a federal law that took effect on January 1, 2022. The primary objective of the law was to protect consumers from most instances of “surprise” balance billing. The legislation was included in the Consolidated Appropriations Act of 2021, which was signed into law in December 2020.
What are “surprise medical bills”?
If you have health insurance and get care from an out-of-network provider or at an out-of-network facility, your health plan may not cover the entire cost of the health care services and/or products (e.g., durable medical equipment like knee braces) you receive. This can result in higher costs than if you got care from an in-network provider or facility.
In the past, in addition to any out-of-network cost-sharing you might owe (like coinsurance or copayments), the out-of-network provider or facility could bill you for the difference between the billed charge and the amount your health plan paid, unless banned by state law. This is called “balance billing.”
An unexpected balance bill from an out-of-network provider is called a surprise medical bill.
Does the No Surprises Act apply to any insurance plan/coverage that I have?
No. The No Surprises Act does not apply to people who are insured/covered by Medicare (including Medicare Advantage plans), Medicaid (including managed Medicaid plans), Indian Health Services, Veterans Affairs Health Care, or TRICARE.
Does the No Surprises Act apply when I receive services in any medical facility or location?
No. The No Surprises Act currently does not apply if you receive your services in a physician’s office/clinic. The No Surprises Act does apply if you receive emergency or non-emergency services in a participating health care facility. A participating health care facility, for purposes of the No Surprises Act, includes hospitals, hospital outpatient departments (e.g., emergency department), critical access hospitals, and ambulatory surgery centers.
What are the new protections if I have health insurance?
If you get health care coverage through your employer, the Health Insurance Marketplace®, or an individual health insurance plan you purchase directly from an insurance company, these No Surprises Act rules will apply. Those rules:
- Ban surprise bills for emergency services, even if you get them out-of-network and without approval beforehand (prior authorization).
- Ban out-of-network cost-sharing (like coinsurance or copayments) for all emergency and some non-emergency services. You can’t be charged more than in-network cost-sharing for these services, and any cost-sharing you pay counts towards your deductible and maximum out-of-pocket limits for the policy year.
- Ban out-of-network charges and balance bills for supplemental services (like anesthesiology or radiology) by out-of-network providers who work at certain in-network facilities (e.g., a hospital or an ambulatory surgical center).
- Require that health care providers and facilities provide you with an easy-to-understand notice explaining that getting care out-of-network could be more expensive and your options to avoid balance bills. You’re not required to sign this notice or get care out-of-network.
If you have a health insurance plan with an out-of-network benefit, like a Preferred Provider Organization (PPO), you can choose to go to an out-of-network provider. However, you can’t be billed more than in-network cost sharing amounts for items or services provided by an out-of-network provider at an in-network facility unless you consent to getting care out-of-network by signing a notice and consent form.
What are the protections if I’m uninsured (i.e., don’t have health insurance) or I choose not to use the insurance coverage I do have?
If you are uninsured/don’t have health insurance or choose not to use the health insurance coverage you do have, the No Surprises Act rules require that a “good faith estimate” (GFE) be provided to you. This GFE provides you with information about how much your care/product/item will cost, prior to receiving your care/product/item. The No Surprises Act rules also allow you to file a dispute if you are charged more than $400 above the GFE/estimate you received.
Can patients still receive balance bills under the No Surprises Act?
Yes. The No Surprises Act doesn’t apply to situations in which a patient chooses to use an out-of-network provider (as opposed to situations in which the patient had no choice or was unknowingly treated by an out-of-network provider at an in-network facility). So, if a person goes to an out-of-network facility or out-of-network doctor in a non-emergency situation, balance billing can still be expected. In these situations, the involved health plan’s normal rules for out-of-network coverage would apply.
In limited non-emergency situations, out-of-network medical facilities and providers can also ask patients to waive their rights under the No Surprises Act. In these cases, if the patient signs a form indicating that he/she agrees to the out-of-network charges, the patient can still receive a balance bill. And the out-of-network medical facility or provider can refuse to provide treatment, unless prohibited by federal or state law, if patients don’t waive their balance billing protections.
Are there exceptions to these protections?
Yes. If you have a vision-only or a dental-only plan, the No Surprises Act protections generally don’t apply to services these plans cover. But if you have a health care plan that includes dental or vision benefits, these protections could potentially apply to any medical, dental, or vision services covered by your health plan.
The balance billing protections generally don’t apply to health care services provided in a physician’s office/clinic. The protections also generally don’t apply to ground ambulance services.
These balance billing protections also don’t apply to people with coverage through Medicare (including Medicare Advantage plans), Medicaid (including managed Medicaid plans), Indian Health Services, Veterans Affairs Health Care, or TRICARE. These programs already have other protections against high and/or unexpected medical bills.
What does Enovis do to comply with the No Surprises Act?
DJO, LLC, Surgi-Care, Inc., Ortho Pros Express, Inc., as well as other DME supplier subsidiaries of Enovis Corporation, are, for purposes of this web page and for the sake of simplicity, all collectively known as “Enovis.” Under the No Surprises Act, Enovis will do the following:
- Enovis will submit a claim (bill) to your insurance plan. Your insurance plan is required by the No Surprises Act to respond to Enovis within 30 days of receiving the claim. When your insurance plan responds, the plan must advise Enovis of the in-network cost-sharing amount for the involved claim AND must indicate that the claim for your product/item has been paid to Enovis.
- Once Enovis receives this information from your insurance plan, Enovis will send you a statement/invoice. That statement/invoice will reflect the in-network cost-sharing amount indicated by your insurance plan on the EOB. This will be the amount you will owe to Enovis for the product you received.
- Enovis may NOT send a statement/invoice to you until the claim has been paid by your insurance plan AND Enovis has been advised of your in-network cost-sharing amount.
- You should also receive an Explanation of Benefits (EOB) directly from your insurance plan that indicates the in-network cost-sharing amount you owe to Enovis and that the Enovis claim has been paid.
- If you are un-insured or choose to NOT use your health insurance, you must receive a Good Faith Estimate (GFE) of the expected amount you will have to pay for your product/service. You MUST receive this GFE before you make a decision about receiving your product/service.
- If you have questions about the statement you received or about the in-network cost-sharing amount you have been billed, you will be able to contact Enovis at NoSurprisesAct@djoglobal.com.
- Enovis must post this disclosure notice summarizing the No Surprises Act surprise billing protections on a public website and give this disclosure to each patient for whom we provide No Surprises Act-covered services or items.