When you receive care from a healthcare provider that is not in your health plan’s network, the “No Surprise” law protects you from balance billing or surprise billing. When you see an out-of-network 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 that is not in your health plan’s network. Out-of-network describes providers who have not signed a contract with your health plan and 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 may be 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 an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
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.
Emergency services: If you have an emergency medical condition and get emergency services from an out-of-network provider, the most the provider 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 post-stabilization services.
When balance billing isn’t allowed, you also have the following protections:
- If your provider is out-of-network, your health plan may or may not cover the services If your provider is in-network, you may be only responsible for paying your share of the cost like the copayments, coinsurance, and deductibles.
- Your health plan generally must a) Cover emergency services without requiring you to get approval for services in advance (prior authorization), b) cover emergency services by out-of-network providers, c) 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, d) 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 visit https://www.cms.gov/nosurprises for more information about your rights under federal law.