Your Rights and Protections Against Surprise Medical Bills
WHEN YOU GET EMERGENCY CARE OR GET 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. IN THESE CASES, YOU SHOULDN’T
BE CHARGED MORE THAN YOUR PLAN’S COPAYMENTS, COINSURANCE AND/OR
What is “balance billing” or “surprise billing”?
When you see a doctor or other health care provider, you may owe certain
out-of-pocket costs, like a copayment, coinsurance, or deductible. You
may have additional costs or have to pay the entire bill if you see a
provider or visit a health care facility that isn’t in your health
“Out-of-network” means providers and facilities that haven’t
signed a contract with your health plan to provide services. Out-of-network
providers may be allowed to bill you for the difference between what your
plan pays and the full amount charged for a service. This is called “balance
billing.” This amount is likely more than in-network costs for the
same service and might not count toward your plan’s deductible or
annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can
happen when you can’t control who is involved in your care—like
when you have an emergency or when you schedule a visit at an in- network
facility but are unexpectedly treated by an out-of-network provider. Surprise
medical bills could cost thousands of dollars depending on the procedure
YOU ARE PROTECTED FROM BALANCE BILLING FOR:
If you have an emergency medical condition and get emergency services from
an out-of-network provider or facility, the most the provider or facility
may bill you is your plan’s in-network cost-sharing amount (such
as copayments, coinsurance, and deductibles). You can’t be balance
billed for these emergency services. This includes services you may get
after you’re in stable condition, unless you give written consent
and give up your protections not to be balanced billed for these post-stabilization
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical
center, certain providers there may be out-of-network. In these cases,
the most those providers can bill you is your plan’s in-network
cost-sharing amount. This applies to emergency medicine, anesthesia, pathology,
radiology, laboratory, neonatology, assistant surgeon, hospitalist, or
intensivist services. These providers can’t balance bill you and
may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network
providers can’t balance bill you, unless you give written consent
and give up your protections.
NEVER REQUIRED TO GIVE UP YOUR PROTECTIONS FROM BALANCE BILLING. YOU ALSO AREN’T
REQUIRED TO GET OUT-OF-NETWORK CARE. YOU CAN CHOOSE A PROVIDER OR FACILITY
IN YOUR PLAN’S NETWORK.
WHEN BALANCE BILLING ISN’T ALLOWED, YOU ALSO HAVE THE FOLLOWING PROTECTIONS:
You are only responsible for paying your share of the cost (like the copayments,
coinsurance, and deductibles that you would pay if the provider or facility
was in-network). Your health plan will pay any additional costs to out-of-network
providers and facilities directly.
Generally, your health plan must:
· Cover emergency services without requiring you to get approval
for services in advance ( also known as “prior authorization”).
· Cover emergency services by out-of-network providers.
· Base what you owe the provider or facility (cost-sharing) on what
it would pay an in-network provider or facility and show that amount in
your explanation of benefits.
· Count any amount you pay for emergency services or out-of-network
services toward your deductible and out-of-pocket limit.