When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
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 a co-payment. You may have other costs or have to pay the entire bill if you see a provider or visit a healthcare facility that is not in your health plan’s network.
“Out-of-network” describes providers and facilities that do not have a fee agreement with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agrees to 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.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—such as 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:
Emergency services
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 may bill you is your plan’s in-network cost-sharing amount (such as co-payments). You can’t be balance billed for these emergency services. This includes services you may get after 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 may 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’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t 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 care out-of-network. 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 (like the co-payment that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
- Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (prior authorization).
- Cover emergency services by out-of-network providers.
- 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.
If you’re concerned or have questions about a balance bill, you may contact the Funds at (646) 473-9200.
If you believe you’ve been wrongly billed, you may contact the U.S. Departments of Health and Human Services, Labor and Treasury’s No Surprises Helpdesk at (800) 985-3059.
Visit the Centers for Medicare & Medicaid Services’ website about ending surprise medical bills, www.CMS.gov/nosurprises, for more information about your rights under federal law.