Your Safeguards Against Unexpected Medical Charges
Under certain conditions, such as during emergencies or when treated by a non-participating provider in a participating facility, you’re shielded from unexpected bills.
Understanding “balance billing” and “surprise billing”
Visiting a healthcare professional may require you to pay out-of-pocket fees like copayments, coinsurance, or deductibles. If you choose a provider outside your health plan’s network, you might face additional charges or even the full bill.
Providers not contracted with your health plan are “out-of-network”. These providers can charge you the difference between your plan’s agreed amount and their service charge, termed “balance billing”. Typically, this is higher than in-network rates for identical services and may not be part of your yearly out-of-pocket max.
Unexpected balance bills arise when you unknowingly receive care from an out-of-network provider, often during emergencies or scheduled visits to in-network facilities.
Balance billing protection covers:
In emergency scenarios, if you receive services from non-participating providers or facilities, they can only charge you up to your plan’s participating cost-sharing amount. Balance billing is prohibited for these emergency services, and this extends to post-emergency care unless you formally consent to waive these rights.
Specific services at participating hospitals or surgical centers
Even in participating hospitals or surgical centers, some providers might be out-of-network. In such cases, these providers can only charge up to your plan’s participating amount for services like emergency care, anesthesia, radiology, and more. They cannot balance bill you without your formal consent. Remember, you always have the option to retain your protection against balance billing and can opt for in-network care.
Your additional rights when balance billing isn’t permissible:
- You only pay your share, equivalent to what you’d pay an in-network provider.
- Your insurance directly compensates out-of-network providers and facilities.
- Emergency services don’t require pre-approval.
- Charges for emergency or out-of-network services count toward your yearly financial responsibilities.
State-Level Balance Billing Safeguards
Beyond these protections, some states offer enhanced balance billing safeguards. Click here to view a list of states and their respective protections. For further details, reach out to your state agency.
If you suspect an incorrect bill, contact your state agency or the Department of Health and Human Services at 1-800-985-3059. For an in-depth understanding of your rights, visit www.cms.gov/nosurprises.
Data on state balance billing protection is courtesy of The Commonwealth Fund. Learn more here.