Your Rights and Protections Against Surprise Medical Bills
Your Rights and Protections Against Surprise Medical Bills
When you get outpatient/emergency care or get treated by an out-of-network provider, you are protected from surprise billing.
What is 鈥渂alance billing鈥� (sometimes called 鈥渟urprise billing鈥�)?
When you see a health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a provider that isn鈥檛 in your health plan鈥檚 network.
鈥淥ut-of-Network鈥� describes providers and facilities that haven鈥檛 signed a contract with your health plan. Out-of-Network 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 鈥渂alance billing.鈥� This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
No Surprises Act Disclosure
鈥淪urprise billing鈥� is an unexpected balance bill. This can happen when you can鈥檛 control who is involved in your care 鈥� 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.
You are protected from balance billing for:
- Out-patient healthcare services. When you get services at an in-network facility, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan鈥檚 in-network cost-sharing amount. Out-of-network providers can鈥檛 balance bill you and may not ask you to give up your protections not to be balance billed unless you give written consent and give up your protections.
- Emergency services. If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan鈥檚 in network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can鈥檛 be balance billed for these emergency services. This includes services you may get after you鈥檙e in stable condition unless you give written consent and give up your protections not to be balance billed for these post-stabilization services.
You鈥檙e never required to give up protections from balance billing. You also aren鈥檛 required to get care out-of-network. You can choose a provider in your plan鈥檚 network.
When balance billing isn鈥檛 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 was in-network). Your health plan will pay out-of-network providers directly.
- Your health plan generally must:
- 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.
- Cover emergency services without requiring you to get approval for services in advance (prior authorization).
- Cover emergency services by out-of-network providers.
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe that you鈥檝e been wrongly billed, visit the CMS website () for instruction about disputing charges as well as additional information about this ruling.