Surprise medical bill ban doesn’t cover some crucial elements. Here’s what to know

Millions of Americans have new federal protections from unexpected medical costs if they see a doctor they did not choose and who doesn’t accept their insurance. For years, the price tag from surprise medical bills could range from hundreds of dollars to tens of thousands. But a new law that took effect at the start of the new year changes that. Jeffrey Brown explains.

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  • Judy Woodruff:

    Millions of Americans have new federal protections from unexpected medical cots if they see a doctor they did not choose and who doesn't accept their insurance.

    For years, the price tag from so-called surprise medical bills could range from hundreds of dollars to tens of thousands. But a new law that took effect at the start new year changes that.

    Jeffrey Brown has the story.

  • Jeffrey Brown:

    The bipartisan No Surprises Act covers nearly all out-of-network emergency procedures, among other care.

    Joining me to explain, Margot Sanger-Katz. She's a health care reporter for The New York Times.

    Welcome to you, Margot.

    First, remind us why this was needed.

  • Margot Sanger-Katz, The New York Times:

    This was actually a pretty big problem.

    People would go to the emergency room. They would have a health problem, or they would have a scheduled surgery or a C-section, something like that, and it would turn out, after they got their care, there was some doctor along the way who was part of their care who didn't accept their insurance.

    And this was a very common thing. About one in five people who went to the emergency room and about one in five people who had a scheduled surgery would end up with a bill from a doctor they didn't choose, and those bills could be thousands, tens of thousands, in some cases hundreds of thousands of dollars, on top of what their insurance covered.

    So, Congress really wanted to address this problem and make it so people did not get these nasty surprises when patients were doing the right thing and going to places where they thought their insurance was going to cover their care.

  • Jeffrey Brown:

    So, a lot of people impacted, a lot of dollars at stake.

    So, how will it work now? What does the new law cover?

  • Margot Sanger-Katz:

    So, it covers a lot of things. It is not perfect. There are a couple of holes that people should know about.

    But if you have a medical emergency and you go to the emergency department of a hospital or you go to an urgent care center, everyone who takes care of you will be covered by your insurance now. If you have a deductible or you pay a cost-sharing of some kind, like a co-payment, you have to pay that just the same as you ever would, but you are not going to get any extra bills from doctors who don't take your insurance.

    Everyone is going to be covered. The one big exception to that is in you take an ambulance, you could get a bill from an ambulance. Congress didn't take care of that problem. It is sort of a complicated policy area. I think they are hoping to get back to it. But I think that is the most important situation.

    If you have an emergency, your insurance is going to cover your emergency room care now.

  • Jeffrey Brown:

    I did notice the exception for the ambulance. It seems a strange one, because, of course, it often is so necessary.

  • Margot Sanger-Katz:

    Yes, it sort of unfortunate, because, of course, an ambulance is a perfect example of a provider you don't pick. You just call 911. And whoever comes, it's not a person you selected.

    You don't have time to shop for an ambulance. But Congress just wasn't able to fix this particular problem. We do know it is a relatively big problem. About half of ambulances do send people bills without just accepting their insurance.

    So it is something that a couple of states have addressed, but the federal government has not gotten to yet.

  • Jeffrey Brown:

    Now, what about the impact, if any, on routine or scheduled care? How would this affect that?

  • Margot Sanger-Katz:

    So, this also provides a lot of consumer protections in that situation.

    So, if you are going to have a scheduled surgery, say you are having a knee surgery or something like that, the hospital where you are having the surgery is covered by your insurance, and the surgeon who is doing the procedure is covered by your insurance, then you don't have to worry about anyone else. There should not be a situation in which, say, an anesthesiologist is not covered or a radiologist.

    Those people are all going to be covered by your insurance. If, for some reason, there is some special doctor that you really want to be there who your insurance doesn't cover, there is a procedure where you can basically sign a form where you say, I'm going to allow this person to send me an extra bill.

    But you have to get notice of that in advance. You have to sign the form. And the form needs to tell you two important things. It has to tell you how much they think it's going to cost, so that you are not surprised when you get that bill. And they also need to tell you, here are some doctors that will take your insurance that you could choose instead.

    So, if you are in a situation where you are having a scheduled procedure and someone gives you that form, look at it really closely. Consumer advocates that I talked to said there are very few situations in which it's really in your interest to sign that form. The hospital needs to be able to provide you with options who will be covered by your insurance.

  • Jeffrey Brown:

    So, it sounds good. It makes the system more transparent, presumably, but what is still on us as consumers. Well, you get a bill, and it looks high, what do you do?

  • Margot Sanger-Katz:

    So I think it's important to remember health policy people call these surprise medical bills, but, of course, they're not the only ways that we get surprised by bills in the system.

    Health insurance is really complicated. Our health care system is really expensive. So what this protects you against is some doctor you didn't pick who's sending you a bill that you weren't expecting.

    But it doesn't mean that you're never going to be surprised by a medical bill. And I think the biggest example where you could get surprised is if you have a really high medical deductible. Even if your care is covered by your insurance, you could still get a bill for up to the amount of that deductible. So I think that's one thing that you need to be aware of.

    And then I think another thing that's important is, if you're going to a doctor, not going to a hospital for a surgery or an emergency procedure, but, say, you're just going to an allergist or a rheumatologist or some other kind of specialist, you do need to make sure that that person is in your insurance network. Those people also can send you bills if they are considered what's called an out-of-network provider.

    That's not exactly the same thing as not accepting your insurance. So, the advice that I would give you is, you want to ask a doctor before you schedule the appointment: Are you in my insurance network?

  • Jeffrey Brown:

    All right, news you can use for consumers, but still a lot to navigate in the health care system.

    Margot Sanger-Katz of The New York Times, thank you very much.

  • Margot Sanger-Katz:

    Thanks so much for having me on.

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