The No Surprises Act is a federal law that protects patients from unexpected medical bills in specific situations. Its protections took effect January 1, 2022, and cover emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services, according to CMS.
For treatment centers, the law matters in two ways. Its emergency protections explicitly include mental health and substance use disorder conditions. And it created the Good Faith Estimate requirement for uninsured and self-pay patients, which reaches behavioral health providers in any setting. Both connect to the billing work inside our admission ops and billing practice.
This entry is general information, not legal advice. Confirm your obligations with counsel.
Key Takeaways
- The No Surprises Act has been in effect since January 1, 2022, and protects patients from surprise bills in three situations: emergency care, out-of-network care at in-network facilities, and air ambulance services.
- CMS defines an emergency medical condition to include mental health conditions and substance use disorders.
- Non-emergency protections apply only at hospitals, hospital outpatient departments, critical access hospitals, and ambulatory surgical centers.
- The Good Faith Estimate requirement for uninsured and self-pay patients applies regardless of clinical setting.
- The surprise billing protections don’t apply to Medicare, Medicaid, and other federal programs, which have their own rules.
What the law covers
Emergency services. Patients can’t be balance billed for emergency services, and cost-sharing is limited to in-network levels. CMS’s provider overview defines an emergency medical condition as including “a mental health condition or substance use disorder.”
Non-emergency care at in-network facilities. When a patient gets care at an in-network facility, out-of-network providers there generally can’t balance bill. The regulation at 45 CFR 149.30 limits “health care facility” for this purpose to four types: hospitals, hospital outpatient departments, critical access hospitals, and ambulatory surgical centers.
Freestanding residential treatment facilities aren’t on that list. Reading the definition, their out-of-network non-emergency care isn’t covered by these protections, though state laws may add their own.
Air ambulance. Air ambulance services get similar protections.
Federal programs. CMS says these requirements don’t apply to people covered by Medicare, Medicaid, the Indian Health Service, Veterans Affairs, or TRICARE.
Notice and consent
In limited cases, an out-of-network provider at a covered facility can ask a patient to waive the protections through a written notice and consent. The rules at 45 CFR 149.420 don’t allow this for emergency services, ancillary services, or unforeseen urgent needs.
Consent can’t be given over the phone, and the notice must come at least 72 hours before the service, or 3 hours for same-day appointments.
Disclosure on the website
Providers and facilities covered by the surprise billing protections must publish a disclosure of patient protections. Under 45 CFR 149.430, it must appear on a searchable homepage, on a sign posted prominently at the location, and as a one-page notice for patients.
It covers the federal protections, any applicable state law, and contacts for state and federal regulators.
That disclosure applies to providers who work at the four covered facility types. The separate notice of the right to a Good Faith Estimate applies more broadly, including to behavioral health providers serving self-pay patients.
The Good Faith Estimate
The No Surprises Act requires providers to give uninsured and self-pay patients a written estimate of expected charges, and to post a notice of that right on their website.
CMS says the requirement applies in every clinical setting, and it uses counseling as an example of a recurring service. See our Good Faith Estimate entry for the timing, content, and dispute rules.
Disputes between providers and plans
When providers, facilities, and health plans disagree about payment for certain out-of-network services, they can use the federal independent dispute resolution process. This is separate from the patient-provider dispute process for Good Faith Estimates.
It starts with a 30-business-day open negotiation period between the plan and the provider or facility. If they don’t agree on a payment amount, either side can begin IDR, where a certified IDR entity chooses between the two parties’ payment offers.
Related terms
For how out-of-network status shapes admissions, see our guides to the VOB-to-admit reimbursement gap, VOB vs expected reimbursement, and single case agreements before admission. For how billing fits the rest of your marketing, see the complete guide to behavioral health marketing.
Frequently Asked Questions
Does the No Surprises Act apply to residential treatment centers?
Partly. The Good Faith Estimate requirement applies to providers in any clinical setting, including residential and outpatient behavioral health, when they serve uninsured or self-pay patients.
The non-emergency surprise billing protections apply at hospitals, hospital outpatient departments, critical access hospitals, and ambulatory surgical centers.
Freestanding residential facilities aren’t on that list, so check state law and confirm with counsel.
Does the No Surprises Act cover mental health and substance use emergencies?
Yes. CMS defines an emergency medical condition to include mental health conditions and substance use disorders.
Patients receiving emergency services are protected from balance billing.
Cost-sharing is limited to in-network levels.
What do treatment centers need to post on their website?
Behavioral health providers serving uninsured or self-pay patients must post a notice of the right to a Good Faith Estimate that’s easy to find, including through search engines.
Providers working at hospitals, hospital outpatient departments, critical access hospitals, or ambulatory surgical centers also need the surprise billing disclosure on a searchable homepage.
Check which apply to your facility type.
Does the No Surprises Act apply to Medicaid patients?
No. CMS says these requirements don’t apply to Medicare, Medicaid, the Indian Health Service, Veterans Affairs, or TRICARE.
Those programs have their own billing protections.
Patients in federal programs also aren’t eligible for Good Faith Estimates.