Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or are treated by an out of network provider or

an in network hospital or ambulatory surgical center, you are protected from

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 doctor or other health care provider, you may owe certain out

of pockets costs such as a copayment, coinsurance, and/or a 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 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 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 can bill you is your plan’s

net 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 are in stable condition, unless you give

written consent and give up your protections not to be balance billed for these

post stabilization services.

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 plans’ 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 balanced billed.

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.

You are never required to give up your protections from balance billing. You

also are not 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 these 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 the amount in your explanation of

benefits.

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

toward your in network deductible and out of pocket limit.

If you believe you have been wrongly billed, contact 1.800.985.3059.

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

rights under Federal law.