Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or are treated by an out-of-network provider at an
in-network hospital or ambulatory surgical center, you are protected from
balance billing. In these cases, you shouldn’t be charged more than your plan’s
copayments, coinsurance and/or deductible.
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,
like a copayment, coinsurance, or deductible. You may have additional 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
“Out-of-network” means providers and facilities that haven’t signed a contract with your health
plan to provide services. Out-of-network providers may be allowed to bill you for the difference
between what your plan pays 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 plan’s deductible or 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. Surprise medical
bills could cost thousands of dollars depending on the procedure or service.
You’re protected from balance billing for:
If you have an emergency medical condition and get emergency services from an out-of-
network provider, facility, the most they can bill you is the plan’s in-network cost-sharing
amount (such as copayments, coinsurance and deductibles). 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.
Certain services at an in-network hospital or ambulatory surgical center
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 can 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 get other types of 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 out-of-network care. You can choose a provider or
facility in the plan’s network.
When balance billing isn’t allowed, you also have these protections:
You’re responsible for paying your share of the cost (like the copayments, coinsurance, and
deductible that you would pay if the provider or facility was in-network). The plan will pay
any additional costs to out-of-network providers and facilities directly.
Generally, the plan will:
o Cover emergency services without requiring you to get approval for services in
advance (also known as “prior authorization”).
o Cover emergency services by out-of-network providers.
o Base what you owe the provider or facility (cost-sharing) for these services on what
the plan would pay an innetwork provider or facility and show that amount in your
explanation of benefits.
o Count any amount you pay for emergency services or these out-of-network services
toward your in-network deductible and out-of-pocket limit.
If you think 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