What is “balance billing” (sometimes called “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” means providers and facilities that haven’t signed a contract with your health plan 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 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. Surprise medical bills could cost thousands of dollars depending on the procedure or service.
Emergency services
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). 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 balance 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:
These providers can’t balance bill you and may not ask you to give up your protections. If you get other types of 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, and you 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 these protections
You’re only responsible for paying your share of the cost — the copayments, coinsurance, and deductible you would pay if the provider or facility were in-network. Your health plan will pay any additional costs to out-of-network providers and facilities directly. Generally, your health plan must:
If you think you’ve been wrongly billed
Contact the federal No Surprises Help Desk at 1-800-985-3059.
Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.
This page reproduces the federal model notice. A PDF copy is also available at assets/no-surprise-billing-act.pdf.