Your Rights and Protections Against Surprise Medical Bills

When you (1) receive emergency care from an out-of-network emergency facility or (2) are treated by an out-of-network provider at an in-network facility, you are protected from balance billing – often called surprise medical bills.

What is “balance billing” (sometimes called “surprise billing”)?

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

Out-of-network describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network 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 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 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.

In what situations are you protected from balanced billing?

Emergency services

If you have an emergency medical condition and get emergency services from certain types of out-of-network emergency facilities, the most the provider or facility may 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 healthcare facility

When you get services from an in-network healthcare facility, certain providers there may be out-of-network providers. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, diagnostic laboratory, neonatology, assistant surgeons, hospitalists, or intensivist services. These providers can’t 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 in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protection 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.

When balance billing isn’t 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 in-network). Your health plan will likely pay its portion of the bill to 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 you would pay an in-network provider or facility and show that amount in your explanation of benefits (EOB).

  • Credit any amount you pay toward a surprise bill to your in-network deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact the No Surprises Help Desk at (800) 985-3059.

The Help Desk, operated by the U.S. Department of Health and Human Services in coordination with the Department of the Treasury, Department of Labor, and the Office of Personnel Management, is a good resource if you’re not sure who to turn to or if you have general questions about the law.

You can also visit WWW.CMS.GOV/NOSURPRISES for more resources.