When you receive emergency care or are treated by an out-of-network doctor or specialist at a hospital or ambulatory surgical center in your plan’s network, you are protected from surprise billing or balance billing.
What Is “Balance Billing” (Sometimes Called “Surprise Billing”)?
When you visit a doctor or other healthcare specialist, you may owe certain out-of-pocket costs, such as a copay, coinsurance, and/or a deductible. If you visit a doctor or specialist or visit a healthcare facility that isn’t in your health plan’s network, you might owe additional charges or be responsible for the entire bill.
“Out-of-network” describes doctors and healthcare facilities that haven’t signed a contract with your health plan. Out-of-network doctors and facilities may be allowed 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 a facility in your plan’s network but are unexpectedly treated by an out-of-network doctor.
You are Protected From Balance Billing For:
If you have an emergency medical situation and receive emergency services from an out-of-network doctor or facility, the most the doctor or facility may bill you is your plan’s in-network cost-sharing amount (such as copays and coinsurance). You cannot be balance billed for these emergency services. This includes services you may receive after you’re in stable condition, unless you give written consent to give up your protections against balance billing once you’re stable.
Certain Services at a Hospital or Ambulatory Surgical Center in Your Plan’s Network
When you receive services from a hospital or ambulatory surgical center (places that perform outpatient surgeries) in your plan’s network, certain doctors or specialists there may be out-of-network. In these cases, the most they 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 specialists cannot balance bill you and cannot ask you to give up your protections not to be balance billed.
If you receive other services at these in-network facilities, out-of-network doctors or other healthcare professionals cannot balance bill you, unless you give written consent to give up your protections.
You’re never required to give up your protections against balance billing. You also aren’t required to receive care out of your plan’s network. You can use the Find Care tool on our website to find doctors and hospitals 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 copay, coinsurance, and deductibles that you would pay if the doctor or facility was in your plan’s network). Your health plan will pay out-of-network doctors and facilities directly.
- Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (also called prior authorization).
- Cover emergency services by out-of-network doctors or specialists.
- Base what you owe the doctor or facility (cost-sharing) on what it would pay a doctor or facility in your plan’s network and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you think you’ve been wrongly billed, you can contact the Employee Benefits Security Administration (EBSA), the No Surprise Help Desk (NSHD) at 1-800-985-3059 or cms.gov/nosurprises or your State Regulator, if your plan is fully insured, to ask whether the charges are allowed by law.