Know Your Rights and Protections Against Surprise Medical Bills
When you receive emergency care or treatment by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. Which means, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.
What is “balance billing” or “surprise billing”?
When you see a health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. If you receive care from an out-of-network provider or at an out-of-network facility, your health plan may not cover the entire out-of-network cost. This can leave you with higher costs than if you got care from an in-network provider or facility. In the past, in addition to any out-of-network cost sharing you might owe, the out-of-network provider or facility could bill you for the difference between the billed charge and the amount your health plan paid, unless banned by state law. This is called “balance billing.”
An unexpected balance bill from an out-of-network provider is also called a surprise medical bill.
“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.
What are the new protections if I have health insurance?
- Ban surprise bills for emergency services, even if you get them out-of-network and without approval beforehand (prior authorization).
- Ban out-of-network cost-sharing (like out-of-network coinsurance or copayments) for all emergency and some non-emergency services. You can’t be charged more than in-network cost-sharing for these services.
- Ban out-of-network charges and balance bills for supplemental care (like anesthesiology or radiology) by out-of-network providers who work at an in-network facility.
- Require that health care providers and facilities give you an easy-to-understand notice explaining that getting care out-of-network could be more expensive and options to avoid balance bills. You’re not required to sign this notice or get care out-of-network.
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 insurance plan’s in-network cost (such as copayments, coinsurance, and deductibles). You cannotbe balance billed for these emergency services. This includes services you may get after you’re in stable condition. The only exception would be if you give written consent and give up your protections not to be balanced 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, some health care providers could be out-of-network. In these cases, the most you can be billed is your insurance 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 cannotbalance bill you and may not ask you to give up your protections to not be balance billed.
If you get other types of services at these in-network facilities, out-of-network providers cannot balance bill you.
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.
For additional information
Visit https://www.cms.gov/nosurprises/consumers for more information about your rights under federal law.
