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Know Your Rights

Know Your Rights

SURPRISE BILLING – YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS

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 also 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.

“Out-of-network” describes providers and facilities that haven’t 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 “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 where a patient did not have notice that treatment was being rendered by an out-of-network provider. 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.

YOU ARE PROTECTED FROM SURPRISE BILLING IN CERTAIN CIRCUMSTANCES:

  • 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’s in network cost-sharing amount (such as copayments and coinsurance). 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 to be balanced billed for these post-stabilization services. The No Surprises Act defines which types of services fall into these categories.
  • Certain services at an in-network hospital or ambulatory surgical center. When you receive 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 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 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 in-network facilities, out-of-network providers can’t balance bill you unless you give written consent. You’re never required to give your consent. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
  • Uninsured/Self-Pay Patients. Some provisions of the No Surprises Act are inapplicable to patients who are uninsured or who are self-pay. Instead, uninsured/self-pay patients are generally entitled to a “good faith estimate” for non-emergency services. Please visit our webpage for more information.

IF BALANCE BILLING ISN’T ALLOWED:

  • 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 is required to pay providers and facilities directly.
  • Your health/insurance plan generally must: cover emergency services without requiring approval in advance (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 that amount in your explanation of benefits; and count any amount you pay for emergency services or out-of-network services towards your deductive and out-of-pocket limit.

SURPRISE BILLING – YOUR GRIEVANCE RIGHTS

If you believe you’ve been wrongly billed, first contact our office. If we can’t resolve your concerns or for more information, you can contact the United States Department of Health and Human Services (https://www.cms.gov/nosurprises) regarding the federal law.