Your Rights And Protections Against Surprise Medical Bills

When you receive emergency care or are treated by an out-of-network doctor or specialist at a hospital or ambulatory surgical center in your plan’s network, you are protected from surprise billing or balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other healthcare specialist, you may owe certain out-of-pocket costs, like a copay, coinsurance, or deductible. If you see a doctor or specialist or visit a healthcare facility that isn’t in your health plan’s network, you might owe additional costs or be responsible for the entire bill.

“Out-of-network” means doctors and healthcare facilities that haven’t signed a contract with your health plan to provide services. Out-of-network doctors and facilities may be allowed to bill you for the difference between what your plan pays 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 plan’s deductible or annual out-of-pocket limit.

“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 doctor. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

You are protected from balance billing for:

Emergency services

If you have an emergency medical situation and receive emergency services from an out-of-network doctor or facility, the most the doctor or facility can bill you is your plan’s in-network cost-sharing amount (such as copays and coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may receive after you’re in stable condition, unless you give written consent to 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 receive services from a hospital or ambulatory surgical center (places that perform outpatient surgeries) in your plan’s network, certain doctors or specialists there may be out-of-network. In these cases, the most they can 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 specialists cannot balance bill you and cannot ask you to give up your protections not to be balance billed.

If you receive other services at these in-network facilities, out-of-network doctors or other healthcare professionals cannot balance bill you, unless you give written consent to give up your protections.

You’re never required to give up your protections against balance billing. You also aren’t required to receive care out of your plan’s network. You can use the Find Care tool on our website to find doctors and hospitals 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 copay, coinsurance, and deductibles that you would pay if the doctor or facility was in your plan’s network). Your health plan will pay out-of-network doctors and facilities directly.
• Your health plan generally must:
  • Cover emergency services without requiring you to get approval for services in advance (also called prior authorization).
  • Cover emergency services by out-of-network doctors or specialists.
  • Base what you owe the doctor or facility (cost-sharing) on what it would pay a doctor or facility in your plan’s network 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 think you’ve been wrongly billed, you can contact the Employee Benefits Security Administration (EBSA), the No Surprise Help Desk (NSHD) at 1-800-985-3059 or cms.gov/nosurprises or your State Regulator, if your plan is fully insured, to ask whether the charges are allowed by law.