Holistic Healing & Wellness No Surprises Act

Effective: January 1, 2022

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 (sometimes called surprise billing).

What is “balance billing” (sometimes called “surprise billing”)?

“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.

You are protected from balance billing for:

• 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 balance billed for these post-stabilization services.

New Jersey law also protects you from being billed for out-of-network services provided on an emergency or urgent basis in an amount in excess of your in-network cost-sharing amount (i.e., the amount your deductible, copayments, or coinsurance would have been if the same services were provided on an in-network basis).

• 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 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’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

New Jersey law also protects you from being billed for inadvertent out-of-network services (services at an in-network facility provided by out-of-network providers) in an amount in excess of your in-network cost-sharing amount (i.e., the amount of your deductible, copayments, or coinsurance would have been if the same services were provided on an in-network basis).

When balance billing isn’t 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 were in-network). Your health plan will pay out-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.

If you believe you’ve been wrongly billed, you may contact the Centers for Medicare & Medicaid Services, Department of Health and Human Services at 1-800-985-3059.

For services rendered in New Jersey, you also may contact the New Jersey Department of Banking and Insurance at 609-292-7272 or file an online complaint at www.state.nj.us/dobi/consumer.htm.

For more information about your rights under federal law, visit www.cms.gov/nosurprises/consumers.

For more information about your rights under New Jersey law, visit www.state.nj.us/dobi/index.html.