Your Rights and Protections Against Surprise Medical Bills

When you receive emergency care or treatment from an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected by law from surprise billing or balance billing. In these cases, you should not be charged more than your plan’s copayments, coinsurance and/or deductible. 

What is “balance billing” (sometimes called “surprise billing”)?

When you see a health care provider, you may owe out-of-pocket costs (copayments, coinsurances, deductibles). If the provider or facility is not in your plan’s network, you may have to pay more costs or the entire bill. “Out-of-network” providers may 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 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 schedule a visit at an in-network facility, but are unexpectedly treated by an out-of-network provider. Surprise bills could cost thousands of dollars, depending on the procedure or service.

You are protected from balance billing for:

• Emergency services. If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most they may bill you is your plan’s in-network costsharing (i.e., copayments, coinsurance). You can’t be balance billed for these emergency services. This includes services after you’re stable, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
• Certain services at an in-network hospital or ambulatory surgical center. Certain providers at an in-network hospital or ambulatory surgical center may be out-of-network. The most those providers may bill you is your plan’s in-network cost-sharing. 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 from balance billing. 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.

You’re never required to give up your protection from the balance billing. Also, remember that if you choose a provider or facility in your plan's network, you will not be balance billed.

When balance billing isn’t allowed, you also have the following protections:
You are only responsible for paying your share of the cost (copayments, coinsurance, and deductibles) you would pay if the provider or facility were in-network. Your health plan will pay out-of-network providers and facilities directly. Your health plan will:

• Cover emergency services without requiring approval in advance (prior authorization).
• Cover emergency services by out-of-network providers.
• Base what you owe the provider or facility (your cost-share) on what the plan would pay an in-network provider and show that amount in your explanation of benefits.
• Count amounts you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact the U.S. Department of Health and Human Services (HHS) at 1-800-985-3059. Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.