Your Rights and Protections Against Surprise Medical Bills
In Accordance with the No Surprises Act (NSA)
When you receive emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.
Balance billing (AKA surprise billing) may occur when your plan does not provide full coverage for your provider’s billed charges and your provider bills you for the difference between what is billed and what your insurance plan allows for payment. This may occur when your provider is out-of-network with your insurance plan and your provider has not negotiated fixed discounted rates with your insurance company. The balance bill 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.
In certain circumstances, surprise medical bills can happen when you can’t control who is involved in your care (e.g., 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.
If you receive emergency services from an out-of-network provider or facility, you are protected from charges that exceed your plan’s in-network cost-sharing amount such as copayments, coinsurance, and deductibles. You cannot be balance billed for these emergency services. This includes services you may receive after you are in stable condition unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
When you receive services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, you are protected from charges that exceed 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 receive other types of services at these in-network facilities such as scheduled elective surgery, out-of-network providers cannot balance bill you, unless you provide written consent and give up your protections. You are never required to give up your protections from balance billing. You are also not required to receive 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 the following protections:
- You are only responsible for paying your cost sharing responsibilities such as copayments, coinsurance, and deductible 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 (AKA prior authorization).
- Cover emergency services by out-of-network providers and determine your cost sharing responsibilities on what you would pay to an in-network provider or facility and show that amount in your explanation of benefits.
- Accrue any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.
If you think you’ve been wrongly billed, contact 1-800-985-3059.
Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.
