Your Rights and Protections Against Surprise Medical Bills
What is “balance billing” or “surprise billing”?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional 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” is when providers and facilities that haven’t signed a contract with your health plan’s network to provide services. Out-of-network providers 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 maximum.
“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.
You are protected from balance billing for:
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 can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You CAN NOT be balance billed for these emergency services. This includes services you may receive once you’re in stable condition, unless 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, certain providers there may be out-of-network. In these cases, the most those providers 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 providers CAN NOT balance bill you and may NOT ask you to give up your protections not to be balance billed. If you get other types of services at these in-network facilities, out-of-network providers CAN NOT balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get 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 share of the cost under your plan (like copayments, coinsurance, and deductibles 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, the health plan must:
- Cover emergency services without requiring you to get pre-approval for services in advance (also known as “pre-certification” or “prior authorization”).
- Cover emergency services by out-of-network providers at in-network benefit levels.
- 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 (EOB).
- Count 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 by your provider, and/or need additional information, visit https://www.cms.gov/nosurprises or https://www.cms.gov/nosurprises/consumers for more information about your rights under federal law.