Frequently Asked Questions on No Surprises Act for Consumers and Providers

 

Understand Your Protections Against Surprise Medical Bills

Have you ever received a medical bill that you weren’t expecting? The No Surprises Act is a law that prevents some surprise medical bills, but the law doesn’t apply to everyone and every situation.

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’re protected from balance billing.

In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and deductible. The notice explaining your rights can be found here.

What is Balance Billing or Surprise Billing?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like 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 health care facility that isn’t in your health plan’s network.

Out-of-network refers to providers and facilities that haven’t signed a contract with your health plan to provide services. 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.

Your balance billing amount is likely more than in-network costs for the same service and may not count toward your plan’s deductible or annual out-of-pocket limit.

Surprise billing is an unexpected balance bill. This can occur when you can’t control who’s 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. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

You’re 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 they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance and deductibles). 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.

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

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

If you get other types of 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 out-of-network care. You can choose a provider or facility in your plan’s network.

In addition to federal law, Minnesota law provides Minnesota residents with similar rights and protections against surprise medical bills for emergency services and unauthorized provider services provided by out-of-network health care providers.

Your Other Protections

When balance billing isn’t allowed, you’re only responsible for paying your share of the cost – like the copayments, coinsurance and deductible – that you would pay if the provider or facility was in-network. Your health plan will pay any additional costs to out-of-network providers and facilities directly.

Generally, your health plan must:

• Cover emergency services without requiring you to get approval for services in advance, also known as 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 in-network deductible and out-of-pocket limit. 

If you think you’ve been wrongly billed, contact the Department of Health & Human Services at 1-800-985-3059. Visit https://www.cms.gov/nosurprises for more information about your rights under federal law. If you are a Minnesota resident, you may also contact the Minnesota Department of Commerce at (651) 539-1600 or (800) 657-3602 for more information about your rights under Minnesota law.

Open Negotiation Process Information and Instructions

A 30-business-day Open Negotiation Period provides disputing parties time to reach an agreement regarding the total out-of-network rate (including any cost sharing) before an Independent Dispute Resolution process begins. The Open Negotiation Period Request Form and additional information can be found here.

Pricing Information

Beginning January 1, 2022 and continuing through January 1, 2024, Sanford Health Plan will begin posting pricing information and tools for covered items and services. In addition to the current tools already available to Sanford Health Plan members, pricing information may also help consumers shop for health care that best fits their needs. In accordance with State and Federal statute, files are updated on a monthly basis to ensure consumers have access to the most recent information. Information posted by Sanford Health Plan represents a good faith reasonable interpretation of applicable regulation. Should a change in law or regulation occur after the information is posted, please check back to make sure you have up to date information in alignment with current regulation.

 

MN Prior Authorization Transparency	RX Drug Price Transparency	Pharmacy Drug Transparency
View the MN Prior Authorization Transparency Report 2023	Search and view prescription drug prices as covered under Sanford Health Plan. File updated 4/01/2024. Drug Pricing lists: (Machine-readable files) Individual plans Small Group plans Commercial plans	Coming soon pending future legislation.