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 health care provider, you may owe certain out-of-pocket costs, such as a co-payment, 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 provider service rates are likely higher and may not count toward your deductible or out-of-pocket limit. 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. This is why it's best to visit network providers whenever possible to reduce your out-of-pocket costs.
“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 co-payments 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.
The above services would be treated the same as if they were in-network, based on what your plan would pay an in-network provider; and count toward your in-network deductible and/or out-of-pocket maximum.
*Ancillary services include services related to emergency medicine, anesthesiology, pathology, radiology and neonatology; certain diagnostic services (including radiology and laboratory services); items and services provided by other specialty practioners; and items and services provided by an out-of-network provider if there is no in-network provider that can provide this service.
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:
- 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.
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket
If I get a surprise bill in one of these situations, what should I do?
You are only responsible to pay your copay, coinsurance, or deductible that would have been charged if you had seen an in-network provider. You should not get - and, if you get, you do not need to pay - a balance or a surprise bill from an out-of-network provider.
If you believe you’ve been wrongly billed, you may contact us as (800) 845-7629 or email your balance bill to email@example.com. If you're submitting a copy of your bill, ensure it is the most recent bill and that you're sending the entire bill, not just the first page.
What if I choose to see an out-of-network provider or visit an out-of-network facility outside of these situations?
Choosing to visit an out-of-network provider or facility under different circumstances means you may face paying the entire bill, because providers are generally not prohibited by law from sending you a surprise bill.
What if I have questions regarding my provider's network status?
If you have questions about a provider's network status, please visit our "Partners" link to visit the provider network site and do a search for the provider in your area. The network contact phone number may also be found on your insurance ID card.
You may visit www.cms.gov/nosurprises for more information about your rights under federal law.