In 2022, the Federal Government implemented legislation to protect consumers of healthcare services from unexpected or surprise billing for care. The No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers. You can learn more about your rights under the No Surprises Act and Transparency Rule here: Transparency in Coverage - Machine Readable Files
When you receive emergency care (other than ground ambulance services) or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or 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 (referred to as "cost-sharing amounts"). 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 the Plan's network.
“Out-of-network” describes providers and facilities that haven’t signed a contract to participate in the Plan's network. 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 does 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.
If you have an emergency medical condition and get emergency services (other than ground ambulance services) from an out-of-network provider, facility, or air ambulance, the most they may bill you is the Plan's in-network cost-sharing amount. You can’t be balance billed for these emergency services. This includes services you may receive 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.
When you receive 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 may bill you is the Plan's in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, 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 receive other services at an in-network facility, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You are never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in the Plan's network.
If you believe you’ve been wrongly billed, you may contact the Department of Health and Human Services (HHS) via its toll-free number at 1-800-985-3059.
Visit https://www.cms.gov/nosurprises/consumers for more information about your rights under federal law.