Rights and Protections Against Surprise Medical Bills

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When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you’re protected from balance billing (sometimes called surprise billing).

What is balance billing?

When you see a doctor or other health care 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 or visit a health care facility that isn’t in your health plan’s network.

Out-of-network is the term used for providers and facilities that haven’t signed a contract with your health plan.

Out-of-network providers 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 when you receive 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:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most they can 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.

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 can bill you is your plan’s in-network cost-sharing amount.

This applies to services for:

emergency medicine
anesthesia
pathology
radiology
laboratory
neonatology
assistant surgeon
hospitalist
intensivist

These providers can't balance bill you and may not ask you to give up your protections not to be balance billed.

Your protections. Your choice.

You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.

If you have trouble finding an in-network provider or facility, you can contact the Pennsylvania Insurance Department at Insurance.PA.gov/NoSurprises or by phone at 877-881-6388 (TTY/TDD: 717-783-3898).

Find a WellSpan Doctor

When balance billing isn't allowed, you also have the following protections:

You’re 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 in-network). Your health plan will pay out-of-network 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 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 limit

More resources about surprise medical bills

What to do if wrongly billed

If you believe you’ve been wrongly billed, you may contact the Pennsylvania Insurance Department at Insurance.PA.gov/NoSurprises or by phone at 877-881-6388 or TTY/TDD: 717-783-3898.

PA Insurance Department

Request bill review

More about your rights

The Pennsylvania Insurance Department has more information about your rights under federal and state law. And the Centers for Medicare & Medicaid Services (CMS) has information from the federal government.

PA Insurance Department

CMS: surprise medical bills

Your federal and state rights

WellSpan can help

For more information about your rights under federal law, you can visit the billing and insurance section of our website or call customer service at 717-851-5005 or 877-631-4262.

Billing and Insurance

This disclosure does not apply to Medicare and Medicaid coverages.