Emergency Claims and The No Surprises Act
The No Surprises Act (NSA) was designed to protect members from surprise out-of-network bills related to emergency situations. It covers hospital and physician fees related to Air Ambulances, Emergency Room visits and downstream care (see here).
Even if a provider is not in-network with your insurance plan, if the claim is regulated by the NSA, it will process:
At the in-network level of benefits (which generally has lower out of pocket costs to members)
The allowed-amount will be set between the Plan and the Provider based on an arbitration process, instead of through billing the member the amount the provider charged not paid by the plan.
Out of Network Ground Ambulance
Ground ambulance claims are NOT covered by the NSA, and thus do not have to have the protections afforded by the No Surprises Act. It is widely considered a failure of congress to carve out these emergency-related claims from the purview of the No Surprises Act, see here.
Many benefit plans might still cover these claims at the in-network level of benefits, but most plans will not pay above the payment limits established in the Plan Document which are generally between 150% and 200% of what Medicare would pay for the expense.
Tips for Out of Network Emergency Ambulance Bills
If you are facing a balance bill from an out-of-network ambulance ride, here are some tips:
Understand the amount your plan paid, and the methodology behind that payment. Generally, your plan processed the claim at an “allowed amount” referencing Medicare.
Understand any cost-sharing applied to the claim, such as copay or coinsurance or deductible.
If the reason behind your ambulance bill is that the ambulance company is out of network and a large portion of your bill is related to the difference between their full billed charges and the amount the plan allowed (at the percentage of Medicare referenced above), you are in a strong position to dispute the bill with the ambulance company.
Tips that often work:
Confirm with the ambulance company that they are charging you more than they would charge Medicare or Medicaid patients. Ask whether they accept Medicare or Medicaid.
Question why the expense was so high.
Know also that depending on your state it is very difficult for the ambulance company to actually collect upon the bill, as many forms of medical debt are no longer allowed to even be reported to credit bureaus.
State Laws and ERISA pre-emption
Some states may have laws regulating health insurance benefits that go beyond what is federally required. Examples:
Around 20 states have laws that govern the payment of Out of Network Ground Ambulances.
Some states may require that there not be benefit limits for certain benefit categories.
Currently, all of the plans Yuzu administers are governed by ERISA and are exempt (“pre-empted”) from most state laws regarding benefits coverage. This means that you may live in a state that has a stricter law for fully-insured plans than it does for your health plan administered by Yuzu, but this does not require your plan to cover these benefits.