Your Rights and Protections Against Surprise Medical Bills
When you get emergency care, or you are treated by an out-of-network provider, you are protected from
surprise billing or balance billing.
What types of plans do these rights and protections apply to?
- Self-funded health benefit plans, including state government and municipal health benefit plans
- Fully insured health benefit plans
- Federal Employees Health Benefit Plan (FEHBP)
- Grandfathered Health Plans
- IF YOU ARE NOT SURE WHAT TYPE OF PLAN YOU HAVE, CONTACT US, WE ARE
HERE TO HELP YOU!
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
copayment, coinsurance, and/or a deductible. You may have other costs or must pay the entire bill if you
see a provider or visit a health care facility that is not in your health plan’s network.
- “Out-of-network” describes providers and facilities that have not 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 an unexpected balance bill. This can happen when you cannot control who is
involved in your care. Examples are 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.
When balance billing is not allowed, you also have the following protections:
- You are only responsible for paying your share of the cost, such as 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.
- You are never required to give up your protection from balance billing. You also do not have to
get care out-of-network. You can choose a provider or facility in your plan’s network.
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 plan’s in-network costsharing amount. This includes copayments, deductibles, and coinsurance. You cannot be balance
billed for these emergency services. This includes services you may get after you are in stable
condition. The exception is if you give written consent and give up your protections not to be
balanced billed for these post-stabilization services.
- Certain services performed by an out-of-network provider at an in-network hospital or
ambulatory surgical center
When you get services from certain out-of-network providers at an in-network hospital or
ambulatory surgical center, those out-of-network providers may not balance bill you or ask you to
sign a written notice and consent form that allows balance billing. You pay only your plan’s innetwork cost-sharing amount. This applies to anesthesia, assistant surgeon, emergency medicine,
hospitalist, intensivist service, laboratory, neonatology, pathology, or radiology.
If you get other services from any other out-of-network providers at in an in-network hospital or
ambulatory surgical center, these out-of-network providers cannot balance bill you, unless you
sign a written notice and consent form that allows balance billing and are provided with a good
faith estimate of your costs from the hospital or ambulatory surgical center before services are
given. If you sign the notice and consent form, you can be balance billed for out-of-network
services. You are not required to sign the notice and consent form. You may seek care from an
available in-network provider.
- Air Ambulance
When you receive medically necessary air ambulance services from an out-of-network provider,
your cost share will be the same amount that you would pay if the service was provided by an innetwork provider. Any coinsurance or deductible will be based on rates that would apply if the
services were supplied by an in-network provider.
Some states have surprise bill/balance billing laws. These laws apply to fully insured plans and may have
an impact on some self-funded plans, including state government or municipal plans and church plans.
Check with your plan administrator and/or booklet to find if state law applies to your coverage.
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.
If you believe you have been wrongly billed:
Please contact the Allied Trades Assistance Program directly with questions or concerns regarding
Behavioral Health Medical Bills received at #800-258-6376.
OR
You may send complaints about potential violations of federal law or state law to:
The U.S. Department of Health & Human Services at:
-
- Phone: 800-985-3059
- Website: https://www.cms.gov/nosurprises/consumers
- Your state agency, which can be located State Contacts for Fed NSA
How to handle services supplied based on inaccurate provider directory information?
If you relied on inaccurate information from our provider directories or website or that we verbally
provided, we hold you harmless. For example, if you received services from a provider that you believed
was in-network based on inaccurate information showing that the provider was in-network, but your
claim was paid as out-of-network. In these situations, contact us — we are here to help. The number is on
the back of your ID card. We will review the claim. After review, you may be responsible only for your
in-network cost share.