Your Rights and Protections Against Surprise Medical Bills

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

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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 plan’s

network.

 

“Out-of-network” means providers and facilities that haven’t signed a contract with your health

plan to provide services. Out-of-network providersmay 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 or service.

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You’re protected from balance billing for:

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Emergency services

If you have an emergency medical condition and get emergency services from an out-of-

network provider or facility, the most they can 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 services.

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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.

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If you get other types of 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.

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You’re never required to give up your protectionsfrom 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.

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When balance billing isn’t allowed, you also have these protections:

• You’re only responsible for paying your share of the cost (like the copayments, coinsurance,and deductible that you would pay if the provider or facility was in-network). Your healthplan will pay any additional costs to out-of-network providers and facilities directly.

• Generally, your health plan must:

o Cover emergency services without requiring you to get approval for services in

advance (also known as “prior authorization”).

o Cover emergency services by out-of-network providers.

o 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.

o Count any amount you pay for emergency services or out-of-network services

toward your in-network deductible and out-of-pocket limit.

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If you think you’ve been wrongly billed, contact 1-800-985-3059.

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Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal

law.