Your Rights and Protections Against Surprise Medical Bills

What is “Balance Billing” (sometimes called “Surprise Billing”)?

When you see a doctor or other healthcare provider, you may owe certain out-of-pocket costs, such as copayments, coinsurance, and deductibles. You may also have other costs, or even pay the full bill, if you see a provider or visit a facility that is not in your health plan’s network.

“Out-of-network” refers to providers and facilities that have not signed a contract with your health plan. Out-of-network providers may bill you for the difference between what your plan pays and the full charge for a service—this is called “balance billing.” This amount is typically higher than in-network costs and might not count toward your plan’s deductible or out-of-pocket limit.

“Surprise Billing” occurs when you receive an unexpected balance bill, often in situations where you cannot control who provides your care, such as emergencies or when you’re at an in-network facility but are treated by an out-of-network provider.

You’re Protected from Balance Billing for:

Emergency Services

If you have an emergency medical condition and receive care at an emergency department (hospital or freestanding), the most an out-of-network provider or facility can bill you is your plan’s in-network cost-sharing amount (e.g., copayments or coinsurance).

You cannot be balance billed for these emergency services, even for any care you receive once you’re stable, unless you give written consent and waive your protections against balance billing for post-stabilization care.

In addition to federal protections under the No Surprises Act, your state may have additional protections that apply to your visit.

Certain Services at an In-Network Hospital or Ambulatory Surgical Center

If you receive services such as emergency medicine, anesthesia, pathology, radiology, laboratory, assistant surgery, or hospitalist care from an out-of-network provider while at an in-network hospital or ambulatory surgical center, the most you will be billed is your in-network cost-sharing amount.

These providers cannot balance bill you or request that you waive your protections against balance billing. For other services at in-network facilities, out-of-network providers may not balance bill you unless you provide written consent to waive your protections.

You are never required to waive your balance billing protections, and you are not obligated to receive out-of-network care. You can always choose a provider or facility within your health plan’s network.

State Protections for Non-Emergency Services

Some states, such as AZ, FL, GA, IN, MD, MA, MI, MN, MO, NM, NE, OK, RI, TN, and VA, provide additional protections for non-emergency services at in-network facilities. You may not be balance billed above your plan’s in-network cost-sharing amount for inadvertent out-of-network services, such as lab testing, or out-of-network services provided on an emergency or urgent basis.

Protections When Balance Billing is Not Allowed

• You are only responsible for paying your share of the costs (e.g., copayments, coinsurance, and deductibles), just as if you received care from an in-network provider or facility. Your health plan will cover any additional costs to out-of-network providers or facilities directly.
• Your health plan must:
  • Cover emergency services without requiring prior authorization.
  • Cover emergency services from out-of-network providers.
  • Base what you owe on in-network provider rates and include this amount in your explanation of benefits.
  • Count any payments you make for emergency or out-of-network services toward your in-network deductible and out-of-pocket maximum.

If You Think You’ve Been Wrongly Billed

If you believe you’ve been wrongly billed by a PreferNP provider or center, please contact us at [email protected].

You can also contact the Centers for Medicare & Medicaid Services (CMS) at 1-800-985-3059 or visit CMS.gov for more information about your rights under federal law. You may also contact your state’s applicable agency for additional protections.