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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.
