Your Rights and Protections Against Surprise Medical Bills
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
When you see a doctor or other health care provider, you may owe certain
out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible.
You may have other 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” describes providers and facilities that haven’t
signed a contract with your health plan. Out-of-network providers may
be permitted to bill you for the difference between what your plan agreed
to pay 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 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 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
may bill you is your plan’s in- network cost-sharing amount (such
as copayments and coinsurance). 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
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
can’t balance bill you, unless you give written consent and give up your protections.
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
- You are only responsible for paying your share of the cost (like the copayments,
coinsurance, and deductibles that you would pay if the provider or facility
was in-network). Your health plan will pay out-of-network providers and
- 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
- Count any amount you pay for emergency services or out-of-network services
toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact the U.S. Department of Health & Human Services at
1-800-985-3059 or by visiting
https://www.cms.gov/nosurprises/consumers for more information about your rights under federal law.
You have the right to receive a “Good Faith Estimate” explaining
how much your medical care will cost
Under the law, health care providers need to give
patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
- You have the right to receive a Good Faith Estimate for the total expected
cost of any non-emergency items or services. This includes related costs
like medical tests, prescription drugs, equipment, and hospital fees.
- Make sure your health care provider gives you a Good Faith Estimate in
writing at least 1 business day before your medical service or item. You
can also ask your health care provider, and any other provider you choose,
for a Good Faith Estimate before you schedule an item or service.
- If you receive a bill that is at least $400 more than your Good Faith Estimate,
you can dispute the bill.
- Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate,
visit www.cms.gov/nosurprises or call to speak to one of our financial
advocates at 828-326-3393.