Medicare and the No Surprises Act: What It Means for You

The No Surprises Act, which took effect January 1, 2022, created federal protections against certain types of surprise billing. But if you have Medicare, you may be wondering whether this law applies to you.

The short answer: it mostly does not apply to Original Medicare because Medicare already has its own protections. But understanding how those protections work can help you avoid unexpected costs.

What Is the No Surprises Act?

The No Surprises Act protects patients with private health insurance from being billed by out-of-network providers without prior notice and consent. It targets: emergency care at out-of-network facilities, non-emergency care at in-network facilities from out-of-network providers (such as an anesthesiologist), and air ambulance services.

Why Medicare Is Different

Medicare already controls what providers can charge:

• Participating providers accept Medicare’s payment rates as payment in full. They can only charge you the standard Deductible and Coinsurance.
• Non-participating providers may charge up to 115% of the Medicare-approved amount (the extra 15% is called an Excess charge).
• Opted-out providers can charge whatever they want for elective care, but must give written notice in advance.

Because Medicare already sets enforceable payment limits, the surprise billing scenario the No Surprises Act addresses largely does not exist in Original Medicare.

Emergency Care Under Medicare

For emergency care, Original Medicare covers care at any Medicare-participating hospital. You pay the standard Part A deductible and coinsurance. You cannot be billed an unexpected extra amount on top of that for emergency services.

What About Medicare Advantage?

This is where the No Surprises Act becomes more relevant. Medicare Advantage Plans are offered by private insurers and operate like private health insurance in some ways. The law’s protections apply to Medicare Advantage just as they apply to other private insurance:

• Emergency care at an out-of-network facility: only in-network cost-sharing applies
• Non-emergency services at an in-network facility from an out-of-network provider: cannot bill more than in-network cost-sharing without advance notice and consent

What the No Surprises Act Does NOT Cover

• Ground ambulance services. Surprise ground ambulance bills remain a significant issue. The law only covers air ambulance.
• Opted-out Medicare providers. Providers who formally opt out of Medicare can still charge private-pay rates to Medicare beneficiaries for elective care.
• Original Medicare directly. Original Medicare’s own payment rules govern what providers can charge.

How Medigap Protects Against Surprise Costs

Medicare beneficiaries with Original Medicare can still face significant out-of-pocket costs. If you see a non-participating provider who charges 115% of the Medicare rate, you owe the 20% standard coinsurance plus the up-to-15% excess charge.

Medigap Plan G covers Part B Excess charges, the extra amount above Medicare’s approved rate that non-participating providers can charge. Plan G also covers the Part A deductible, Part A hospital coinsurance, Part B coinsurance, Skilled nursing facility coinsurance, and foreign travel emergency (up to plan limits).

Plan F covered excess charges as well but is no longer available to people who became Medicare eligible on or after January 1, 2020. Plan G is the most comprehensive plan available to new Medicare enrollees.

Practical Steps to Protect Yourself

1. Ask before scheduling non-emergency procedures. Confirm all providers involved are in-network.
2. Confirm provider status for Original Medicare. Ask whether they are a participating Medicare provider or search Medicare.gov.
3. Review your Medicare Summary Notice after receiving care to ensure billing matches what you received.
4. Know your Appeal rights if you receive an improper bill.

The Bottom Line

The No Surprises Act was designed primarily for private insurance. If you have Original Medicare, its direct application to your situation is limited. If you have Medicare Advantage, the law’s protections against surprise bills do apply. Either way, a Medigap plan that covers excess charges is the most reliable way to avoid financial surprises.

Want to understand exactly what your Medicare coverage leaves exposed? A REMEDIGAP advisor can walk you through your options at no cost.

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