Patients who get emergency care or get medical treatment at an out-of-network provider or at an in-network hospital or ambulatory surgical center (ASC), are protected from what is known as “surprise billing” or “balance billing”.

What exactly is “balance billing / “surprise billing”?

When you visit a doctor or other healthcare providers, you may owe out-of-pocket fees, including a copayment, (co-pay) coinsurance, and/or your health insurance deductible. You may have other/additional costs or have to pay the entire bill if you see a provider or visit a healthcare facility that isn’t in your health plan’s network.

“Out-of-network” is a term used to describe doctors or other medical providers as well as facilities such as surgery centers (ASC’s) that are not contracted with your health plan. Out-of-network providers may be allowed to bill you for the difference between what your insurance plan has agreed to pay and the total amount that is charged for 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 a balance bill that is unexpected. This can occur when you are not able to control who is involved in your care—such as when you have an emergency room visit or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

Patients should know that they are protected from balance billing for the following:

Emergency services

If you are in need of emergency medical care or have an emergency medical condition and get emergency services from an out-of-network provider or in an out-of-network facility, the most the provider or facility is allowed to bill you is your plan’s in-network cost-sharing amount.  You cannot be balance billed for these emergency services. This includes services you may get even when you are in stable condition, unless you give written consent and give up your protections not to be balanced billed for post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get care at an in-network hospital or ambulatory surgical center (ASC), certain providers at these facilities may be out-of-network. In these instances, the most that out-of-network providers may 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 are not able to 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 they have written consent from you and you give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. 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 insurance plan will pay out-of-network providers and facilities directly.
• Your health insurance plan generally must
  • Cover emergency services without the requirement that you get approval for the services in advance (prior authorization).
  • Cover emergency services performed 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.

If you believe you’ve been wrongly billed, you have the right to contact the federal surprise billing hotline toll free at 1-800-985-3059 or visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.