No Surprise Act
South Dakota Surprise Billing Protections
Effective January 1, 2022, the No Surprises Act protects patients from surprise bills for emergency services at out-of-network facilities or for out-of-network providers at in-network facilities, holding patients liable only for in-network cost-sharing amounts. Additionally, uninsured patients are entitled to receive a good faith estimate of the cost of care.
Billing Disclosures – Your Rights and Protections Against Surprise Medical Bills
When you receive emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
What is “Balance Billing”?
Balance billing, also known as surprise billing, occurs when you receive care from an out-of-network provider and are charged for the difference between what your health plan pays and what the provider charges. This amount can be significantly higher than in-network costs and may not count toward your annual out-of-pocket limit.
You are protected from balance billing for:
- **Emergency Services**: If you receive emergency care, you cannot be balance billed, regardless of whether the provider is in-network or out-of-network.
- **Certain Services at In-Network Facilities**: When receiving care at an in-network hospital or ambulatory surgical center, some providers may be out-of-network. In these cases, you may only be billed for your plan’s in-network cost-sharing amount for services such as emergency medicine, anesthesia, pathology, radiology, laboratory, and certain surgical services.
You are never required to waive your protections against balance billing, and you have the right to choose a provider or facility within your health plan’s network.
South Dakota Protections Against Balance Billing
South Dakota law offers protections similar to those outlined in the No Surprises Act. Patients receiving covered services at an in-network facility by an out-of-network provider are only responsible for their in-network cost-sharing amount. If you consent to receive services from an out-of-network provider in advance, balance billing protections may not apply.
When Balance Billing Isn’t Allowed, You Have the Following Protections:
– You are only responsible for your share of the costs (copayments, coinsurance, and deductibles) as if you received care from an in-network provider.
– Your health plan will pay out-of-network providers directly.
– Your health plan must cover emergency services without requiring prior authorization.
– Cost-sharing amounts are based on what your plan would pay an in-network provider, and this amount will be reflected in your explanation of benefits.
– Any amount paid for emergency services or out-of-network services will count toward your deductible and out-of-pocket limit.
Reporting Issues
If you believe you’ve been incorrectly billed, you can contact:
– The U.S. Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (1-800-633-4227) or visit cms.gov for more information about your rights under federal law.
– The South Dakota Division of Insurance at 1-605-773-3563 or visit insurance.sd.gov for more information about your rights under South Dakota law.
Good Faith Estimate
You have the right to receive a “Good Faith Estimate” that outlines how much your medical care will cost. Healthcare providers must provide an estimate of the bill for medical items and services to patients who do not have insurance or are not using insurance.
– You are entitled to a Good Faith Estimate for the total expected cost of any non-emergency items or services, including related costs like medical tests, prescription drugs, equipment, and hospital fees.
– Ensure that your healthcare provider provides a Good Faith Estimate in writing at least one business day before your medical service or item. You can also request a Good Faith Estimate from any provider before scheduling a service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill. Be sure to keep a copy of your Good Faith Estimate for your records.
Get More Information
For questions or more information about your right to a Good Faith Estimate, visit cms.gov or call 1-800-MEDICARE (1-800-633-4227).
