Understanding Surprise and Balance Billing: A Guide for Medicare Beneficiaries | 08.01.2025
We’re shining a light on an important issue: many beneficiaries encounter unexpected bills, often leading to frustration and confusion. It can feel like companies rely on individuals not having the information or energy to challenge them. That’s where we come in.
Read on to empower yourself with essential knowledge about balance billing, also known as surprise billing…
What is Balance Billing?
Balance billing, or surprise billing, happens when healthcare providers charge you the difference between their fees and what your insurance covers. This often occurs unexpectedly, especially in emergencies or when receiving care from out-of-network providers at in-network facilities.
Protections Under the No Surprises Act (Effective January 1, 2022)
The No Surprises Act, part of the Consolidated Appropriations Act of 2021, provides essential protections:
Emergency Care: All emergency services are treated as in-network, regardless of the provider, with no prior authorization needed.
Non-Emergency Services: If you receive care at an in-network facility but can’t choose your provider, you cannot be balance billed.
Air Ambulance Services: Similar protections apply, preventing balance billing from out-of-network air ambulance providers.
Dispute Resolution: Payment disputes between providers and insurers are resolved through an Independent Dispute Resolution (IDR) process, keeping you out of the conflict.
Positive Impact So Far
A 2024 survey found that the No Surprises Act prevented over 10 million surprise bills in the first nine months of 2023, with nearly 80% of out-of-network providers accepting initial in-network payments from insurers.
Medicare Beneficiaries and Balance Billing
Original Medicare: Strictly prohibits balance billing. Providers who don’t accept assignment can only bill you up to a capped amount, and private contracts require your consent in advance.
Medicare Advantage Plans: Offer similar protections against surprise billing in emergencies or when referred by in-network providers.
What You Can Do
Know Your Rights:
Emergency and air ambulance services are always billed as in-network.
Out-of-network care at in-network facilities is protected.
Decline Network Waivers:
If presented unexpectedly, especially during emergencies, do not sign them.
Review Your Explanation of Benefits (EOB):
If you receive a surprise bill, file a complaint with CMS or your State Insurance Commissioner, and consider appealing under the No Surprises Act.
Consult Your Broker:
A knowledgeable advisor can help you navigate these rules and ensure you’re informed of your rights.
Current Landscape for Beneficiaries
As of this writing, no federal changes are expected that would weaken balance billing protections for Medicare or Medicare Advantage enrollees. In fact, Congress is considering stronger enforcement laws, and the Centers for Medicare & Medicaid Services (CMS) is enhancing dispute resolution processes and improving hospital billing transparency to further support beneficiaries.
Bottom Line
The No Surprises Act and Medicare regulations provide strong safeguards against balance billing. Recent policy updates continue to reinforce these protections. Navigating complex healthcare billing can be challenging, so having a dedicated broker year-round is essential to avoid unexpected costs.
If you receive a surprise bill, don’t pay it immediately. Reach out to us; we’ll review your coverage together, then guide you through the next steps.
Need help with a bill you’ve received or with understanding your rights? Book an appointment - we provide support all year, not just during enrollment season!
