The No Surprises Act and Dental Care: Don’t Be Surprised When It Affects You

Beginning Jan. 1, 2022, a new law called the "No Surprises Act" went into effect to protect patients and healthcare consumers from unexpected medical bills. The law is intended to prevent "surprise" bills from out-of-network care providers and emergency services that patients did not realize their insurance didn't cover.

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Does the No Surprises Act apply to dental care?

Some, but not all, regulations of the No Surprises Act apply to dental care. Specifically, balance billing regulations largely don’t apply while good-faith estimates for uninsured and self-paying patients do apply.

After many questions reached the American Dental Association, the organization provided private offices with better guidance about what to expect from this new law. The ADA guidance currently says that some dental services provided by hospitals could be affected by the No Surprises Act if they are billed through the facility. For instance, if a hospital provides oral surgery as part of reconstructive surgery, that would not be excluded.

Balance billing rules don't apply to dental plans

Balance billing excludes "excepted benefits," which includes stand-alone dental plans. Excepted benefits are noncovered benefits that the patient has been made aware of by their insurance plan. The patient will have to pay for these services out of pocket.

All insurance plans include items or services which will not be covered, often listed as "exceptions" or "exclusions." A patient will be charged full price for these services or items. For instance, a plan may cover 100% of hospital coverage except for in-hospital psychiatric care. If a patient needed such care during the stay, they would have to pay for their psychiatric care. Balance billing rules do not include these benefits since they were already discussed in the insurance plan, and the patient was aware they would be billed.

Balance billing splits other costs into "covered" and "not covered" payments. For instance, if a plan pays 80% of the bill after the co-pay, balance billing deducts the co-pay, subtracts the 80% coverage, and then charges the patient 20% of the bill. The No Surprises Act is meant to prevent that "surprise bill," which can be very large for an extended stay in the hospital.

Balance billing rules under the No Surprises Act now prohibit charging the patient for any costs not paid by the insurer. This does not apply to dental plans. Dental plans are allowed to surcharge patients for unpaid costs.

Good faith estimate regulations do apply to dental providers

The good-faith estimate regulations apply to all dental providers. Dental providers and facilities must follow the same estimate guidelines and timelines as other medical providers. As detailed below, uninsured and self-paying patients must receive a good-faith estimate within three days of requesting a summary of their expected costs for services and items.

Which dental patients must receive good faith estimates?

Uninsured and self-paying patients who request an estimate must receive a good-faith estimate no less than three days before any treatment. The estimate must be a reasonable estimate of the services and procedures expected.

If the patient is already undergoing treatment, or there is no time for a good-faith estimate, the estimate must include a disclaimer stating the estimate is only for services "reasonably expected" to be furnished.

Which dispute resolution processes apply to dental care?

Whether the dispute concerns a medical bill or a dental treatment, the Centers for Medicare and Medicaid Services (CMS) handles billing disagreements through the Patient-Provider Dispute Resolution (PPDR) process. An uninsured patient can request dispute resolution if there is more than a $400 discrepancy between the good-faith estimate and the actual bill. The discrepancy must be $400 for each provider or doctor, not $400 in aggregate. 

Good faith estimate content requirements for dentists

The provider's good-faith estimate needs to include the following:

• A list of items and services expected to be provided for the period of care
• Any services that might be provided by an outside agency associated with the facility (e.g., if an oral surgeon uses an anesthesiologist, that individual's costs and services must be included in the estimate)
• Diagnostic and service codes
• Notification that if the bill is significantly higher than the estimate, it may be updated, negotiated, or financial assistance may be provided
• Dispute resolution information and instructions on how to dispute the bill if it is more than $400 over the good-faith estimate

Complete guidance for good-faith estimates can be found here.

Timeline for sending GFE to dental patients

When dental providers and facilities receive a request from an uninsured or self-paying individual for an estimate of services or they are scheduling an item or service for such an individual, they are required by the No Surprises Act to contact all other providers or facilities who may assist with such services no less than one day after the request.

The good-faith estimate timelines are as follows:

• When the service is scheduled at least three business days before the date of treatment, the estimate must be provided no later than one day after the date of scheduling.
• When service is scheduled at least 10 business days before the date of treatment, the estimate must be provided no later than three business days after the date of scheduling.
• When an uninsured or self-paying individual requests an estimate, the good-faith estimate must be provided no later than three business days after the date of the request.

The No Surprises Act went into full effect as of January 2022, and guidance for dental providers was released in March. Rules on litigation and payment of settlements were enacted in August 2022. The implementation of this Act has been slow and probably hindered by the COVID emergency, which slowed its introduction into the dental marketplace.

The ADA continues to update members about changes and guidance in implementing the No Surprises Act as it affects dentists and dental care. It recommends directing any questions and concerns to their office.

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