Your Rights and Protections Against Surprise Medical Bills When you get emergency care or get treated by an outofnetwork provider at an innetwork 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 outofpocket 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 isnt in your health plans network

Outofnetworkdescribes providers and facilities that havent signed a contract with your health plan. Outofnetwork 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 innetwork costs for the same service and might not count toward your annual outofpocket limit

Surprise billingis an unexpected balance bill. This can happen when you cant control who is involved in your carelike when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an outofnetwork provider

You are protected from balance billing for

Emergency services 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 plans in-network costsharing amount (such as copayments and coinsurance). You cant be balance billed for these emergency services. This includes services you may get after youre in stable condition unless you give written consent and give up your protections not to be balanced billed for these poststabilization services

Certain services at an innetwork hospital or ambulatory surgical center When you get services from an innetwork hospital or ambulatory surgical center, certain providers there may be outofnetwork. In these cases, the most those providers may bill you is your plans innetwork costsharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers cant 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 innetwork facilities, outofnetwork providers cant balance bill you, unless you give written consent and give up your protections

Youre never required to give up your protections from balance billing. You also arent required to get care outofnetwork. You can choose a provider or facility in your plans network

When balance billing isnt allowed, you also have the following protections

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 innetwork). Your health plan will pay outofnetwork providers and facilities directly

    • Your health plan generally must:
      • Cover emergency services without requiring you to get approval for services in advance (prior authorization)
      • Cover emergency services by outofnetwork providers
      • Base what you owe the provider or facility (costsharing) on what it would pay an 
      • innetwork provider or facility and show that amount in your explanation of benefits
      • Count any amount you pay for emergency services or outofnetwork services 
      • toward your deductible and outofpocket limit

If you believe youve been wrongly billed, you may contact us.