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Your rights and protections against surprise medical bills
When you get emergency care or get treated by a nonparticipating provider at a participating hospital or ambulatory surgical center, you are protected from balance billing.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other 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 plan’s network.
“Nonparticipating” describes providers and facilities that haven’t signed a contract with your health plan. Nonparticipating providers may be permitted to bill you for the difference between what your plan agreed to pay 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 — such as when you have an emergency or schedule a visit at a participating facility but are unexpectedly treated by a nonparticipating provider.
You are protected from balance billing for:
- Emergency services
If you have an emergency medical condition and get emergency services from a nonparticipating provider or facility, the most the provider or facility may bill you is your plan’s in-network out-of-pocket 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 services.
- Certain services at a participating hospital or ambulatory surgical center
When you get services from a participating hospital or ambulatory surgical center, certain providers there may be nonparticipating. In these cases, the most those providers may bill you is your plan’s in-network out-of-pocket 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 participating facilities, nonparticipating providers can’t balance bill you unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get care from a nonparticipating provider. 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’re only responsible for paying your share of the cost such as copayments, coinsurance and deductibles that you would pay if the provider or facility was in network. Your health plan will pay nonparticipating providers and facilities directly
- Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (prior authorization)
- Cover emergency services by nonparticipating providers
- Base what you owe the provider or facility (out-of-pocket costs) 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 services rendered by nonparticipating providers in the circumstances outlined above toward your deductible and out-of-pocket limit.
If you believe you’ve been incorrectly billed, contact the No Surprises Help Desk at 1-800-985-3059.