Medical Billing Rights

What is Balance Billing ( also known as Surprise Billing ) ?

Balance billing occurs when you receive services from a healthcare provider or facility that is not part of your health plan's network. In these cases, you may be billed for the difference between what your health plan pays and what the provider charges. This can happen even if you’ve already paid your required copayments, coinsurance, or deductible.

Providers who are "out-of-network" do not have a contract with your health plan, which means they may bill you for the difference between the amount your health plan agrees to pay and the total charge for the service. This difference can often be higher than what you would pay for the same service from an in-network provider and may not count toward your annual out-of-pocket maximum.

What is Surprise Billing?

Surprise billing is a form of balance billing that occurs when you unexpectedly receive care from an out-of-network provider. This often happens when you have no control over who provides your care—such as in emergencies or when you visit an in-network facility and are unexpectedly treated by an out-of-network provider.

Protections Against Balance Billing

As of recent legislation, you are protected from balance billing under the following circumstances:

• Emergency Services: If you have a medical emergency and receive emergency services from an out-of-network provider or facility, the provider can only bill you for your plan's in-network cost-sharing amount (like copayments and coinsurance). You cannot be balance billed for these emergency services, including post-stabilization services, unless you provide written consent to waive these protections.
• Certain Services at In-Network Hospitals or Ambulatory Surgical Centers: If you receive care at an in-network hospital or ambulatory surgical center, some providers — such as those offering emergency medicine, anesthesia, radiology, and more — may be out-of-network. In such cases, these out-of-network providers can only bill you for your plan’s in-network cost-sharing amount. They are prohibited from balance billing you and cannot ask you to waive your protections.

For other services at in-network facilities, out-of-network providers cannot balance bill you unless you provide written consent to forgo these protections.

Your Rights Regarding Balance Billing

You are never required to give up your protections against balance billing.

You are not required to choose care from an out-of-network provider. You can choose any provider or facility that is within your health plan's network.

Additional Protections When Balance Billing Isn’t Allowed

When balance billing is not permitted, you have the following rights:

You are only responsible for paying your health plan’s in-network cost-sharing amount (such as copayments, coinsurance, or deductibles). Your health plan will pay out-of network providers directly.

• Emergency services: Your health plan must cover emergency services without requiring prior approval (also known as "prior authorization").
• Out-of-network providers: Emergency services provided by out-of-network providers must still be covered by your plan.
• Cost-sharing: The amount you owe for emergency or out-of-network services will be based on the amount your health plan would pay an in-network provider for the same service. This amount will be shown in your explanation of benefits (EOB).
• Deductibles and out-of-pocket maximums: Any amount you pay for emergency or out of-network services will count toward your deductible and annual out-of-pocket limit.

If You Believe You’ve Been Wrongly Billed

If you believe you’ve been incorrectly billed for services, you have the right to file a complaint. You can contact The Centers for Medicare and Medicaid Services (CMS) at 1-800-985-3059 for assistance.

For more information about your rights under federal law, visit Centers for Medicare & Medicaid Services - No Surprises consumers.