No Surprises Act

The federal No Surprises Act protects patients from certain unexpected medical bills. This page summarizes those protections in plain English. It is a standard federal notice, not legal advice.

Medical services at our Texas clinic locations are provided by Lifeline Urgent Care, an independent medical practice. Billing questions about care you received can be directed to the clinic where you were treated.

What Is “Balance Billing”?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs such as a copayment, coinsurance, or deductible. You may have additional costs, or have to pay the entire bill, if you see a provider or visit a facility that is not in your health plan's network.

“Out-of-network” means providers and facilities that have not signed a contract with your health plan. Out-of-network providers may be allowed to bill you for the difference between what your plan pays 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 plan's deductible or annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. It can happen when you cannot control who is involved in your care — like in 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 cannot be balance billed for these emergency services, including services you may get after you are in stable condition, unless you give written consent and give up your protections.

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 cannot balance bill you and may not ask you to give up your protections not to be balance billed.

You are never required to give up your protections 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.

Some states, including Texas, provide additional balance-billing protections under state law for state-regulated health plans.

When Balance Billing Is Not Allowed, You Also Have These 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 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 on what it would pay an in-network provider, and count any amount you pay toward your deductible and out-of-pocket limit.

Good Faith Estimate for Uninsured and Self-Pay Patients

If you do not have insurance or you choose not to use your insurance, you have the right to receive a Good Faith Estimate of the expected cost of your care, in writing, before your scheduled service — and you can ask for one at any time before you schedule. The estimate covers the expected charges for the items and services reasonably expected to be part of your visit.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill through the federal patient-provider dispute resolution process. Keep a copy of your estimate.

If You Believe You Have Been Wrongly Billed

Contact the federal No Surprises Help Desk at 1-800-985-3059 or visit cms.gov/nosurprises for more information about your rights under federal law, to get a dispute process started, or to file a complaint.

Questions?

If you have questions about a bill from one of our clinic locations, call the clinic where you were treated, or contact us at info@hybridhealthsystem.com.