When you get emergency care or get 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.
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 have to 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 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 cannot control who is involved in your care. For example, 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:
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 cost-sharing amount (such as copayments and coinsurance). You cannot be balance billed for these emergency services. This includes services you may get after you are in stable condition unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
[**See appendix for State Laws regarding Balance Billing]
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 may bill you is your 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 cannot 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 cannot balance bill you, unless you give written consent and give up your protections.
You are never required to give up your protection from balance billing. You also are not required to get care out-of-network. 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 pay out-of-network providers and facilities
- 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
- 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
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket
If you believe you’ve been wrongly billed, you may contact us at 888-703-3301.
Visit Website: www.cms.gov/nosurprises for more information about your rights under federal law. Please visit your state’s websites for specific state laws.
Appendix: State Laws
|State||State Balance Billing Laws|
|Alabama||No prohibition for balance billing.|
|Arizona||Arizona law states, An enrollee is not liable to the provider or hospital for any amounts owed by the organization and the provider or hospital shall not bill or otherwise attempt to collect from the enrollee the amount owed by the organization. Ariz. Rev. Stat. §20-1072|
|Arkansas||No prohibition on non-participating providers|
|California||California law states, an enrollee shall not owe the noncontracting individual health professional more than the in-network cost-sharing amount for services subject to this section. A noncontracting individual health professional shall not bill or collect any amount from the enrollee for services subject to this section except for the in-network cost sharing amount. Cal. Health & Saf. Code § 1371.9|
|Colorado||Colorado law states that covered services rendered by an out-of-network provider, shall be covered at no greater cost to the covered person than if the services or treatment were obtained from an in-network provider. Colo. Rev. Stat. §10-16-704|
|Connecticut||Effective July 1, 2016, Connecticut law prohibits providers from balance billing an enrollee for health care services covered under a healthcare plan; emergency services covered under a health care plan and rendered by an out of network provider; or surprise bills. Conn. Gen. Stat. § 20-7f(b)|
|Delaware||Delaware law requires managed care organizations to prohibit balance billing by non-participating providers under network adequacy standard. 18-1300-1316 Del. Admin. Code § 11.3.|
|Florida||Florida law prohibits both participating and non-participating providers from balance billing a HMO enrollee when the HMO is liable for the services rendered or when the provider knows in good faith or should know that the HMO is liable. Florida also prohibits nonparticipating providers from balance billing for covered emergency medical services and applies the HMO non-par billing limitations from F.S. 641.513(5).|
|Georgia||Effective January 1, 2021, Georgia law prohibits balance billing. Ga. Code. Ann. § 33-20E-2; Ga. Code. Ann. § 33-20E-7|
|Illinois||Illinois law prohibits balanced billing for nonparticipating physicians except for applicable deductible, copayment, or coinsurance amounts that would apply if the beneficiary, insured, or enrollee utilized a participating physician for covered services. The nonparticipating provider is prohibited from balanced billing the patient if the patient signs an Assignment of Benefits (AOB) to the nonparticipating facility-based provider. 215 ILCS 5/356z.3a.|
|Indiana||Indiana state law prohibits providers from balanced billing HMO enrollees for “care obtained in an emergency,”. Providers may not charge the enrollee except for an applicable copayment or deductible. Care provided to an enrollee who is stabilized is not care obtained in an emergency. Ind. Code § 27-13-36-9(d)|
|Iowa||No laws against non-participating providers balanced billing|
|Kansas||Kansas state law only prohibits balanced billing when the patient is a subscriber of a nonprofit medical and hospital service corporation. Kan. Stat. Ann. § 40-2,117|
|Kentucky||No laws against balanced billing|
|Louisiana||No law against balance billing|
|Michigan||Michigan law does not allow a non-participating provider to collect or attempt to collect from any patient any amount other than the applicable in-network coinsurance, copayment or deductible. MCL 333.24502|
|Minnesota||Minnesota law requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing. This law applies to HMO and PPO enrollees for non-emergency services provided by out-of-network professionals at in-network facilities. These protections do not apply to emergency services or self-funded plans. Minnesota Statues 62Q.556|
|Mississippi||Mississippi law prohibits out of network providers from billing any amount beyond in-network cost sharing when provider accepts assignment of benefits. These protections apply to emergency and non-emergency services. Miss. Code Ann. § 83-9-5|
|Missouri||Missouri law prohibits a nonparticipating provider from balance billing when the patient presents with an emergency medical condition. (Mo. Rev. Stat. § 376.690(3)) The definition of emergency medical condition can be found at MO. Rev. Stat. § 376.1350(12).|
|Montana||No law against balance billing|
|Nebraska||Nebraska law prohibits out-of-network professionals and facilities from billing enrollees for any amount beyond in-network cost sharing. These protections apply for HMO and PPO enrollees when emergency services are provided. Nebraska LB997|
|Nevada||Nevada Assembly Bill 469 prohibits out of network providers from billing enrollees for any amount beyond in-network cost sharing. These protections apply to HMO, PPO and enrollees of self-funded plans when receiving emergency services only.|
|New Jersey||New Jersey’s Out-of-Network Consumer Protection, Transparency, Cost Containment, and Accountability Act prohibits providers from balance billing a covered person for inadvertent out-of-network services and/or out-of-network services provided on an emergency or urgent basis above the cost-sharing amount. P.L. 2018, c.32|
|New Mexico||New Mexico prohibits balance billing for emergency services. The covered person is only responsible for payment of applicable in-network cost sharing amounts. NM Stat. § 59A-57A|
|New York||New York law states that health care plans shall ensure that the insured or enrollee shall incur no greater out of pocket costs for emergency services than the insured or enrollee would have incurred with a health care provider that participates in the health care plan’s provider network. N.Y. Ins. Law § 3241(c)|
|North Carolina||In North Carolina, a non-participating provider is not prohibited from balance billing.|
|Ohio||Ohio state law prohibits providers from balance billing a patient for unanticipated out of network care. Ohio Rev. Code § 3902.50|
|Oklahoma||No prohibitions for nonparticipating providers|
|Pennsylvania||Under Pennsylvania law a non-participating provider is not prohibited from balance billing except in the cases of “continuity of care” services, Medicare services and worker’s compensation. See 40 Pa. Cons. Stat. § 991.2117(e); 31 Pa. Cons. Stat. §154.1534 and Pa. Code §127.211|
|South Carolina||No statutes prohibiting balance billing|
|Tennessee||No statutes prohibiting providers from balance billing only facilities|
|Texas||Texas does not permit balance billing for emergency services and non-network facility-based provider services. Tex. Ins. Code § 1271.008 and Sec. 1271.155|
|Virginia||Virginia prohibits out-of-network providers from balance billing an enrollee for emergency services and/or nonemergency services provided to an enrollee at an in-network facility. Va. Code Ann. § 38.2-3445.01|
|Washington||Washington restricts out of network providers from charging to patients an amount above the charge if the care had been provided in-network. RCW § 48.43.005|
|West Virginia||West Virginia law prohibits balance billing for only contracted HMO providers. These prohibitions do not apply to non-contracted providers of emergency services. W. Va. Code § 33-25A-7a.|
|Wisconsin||Wisconsin prohibits non-participating providers from balance billing HMO enrollees. Wis. Stat. § 609.91|