No Surprises Act:
Your Rights and Protections Against Surprise Medical Bills
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 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 your health plan's contract rate and the full amount charged for a service. This is called balance billing. “Surprise billing” is an unexpected balance bill.
Under the new No Surprises Act, you are protected from balance billing for:
- Emergency services - If you have a medical emergency 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. You cannot be balance billed for these emergency services. This includes services you may get after you are in stable condition, unless you have given written consent and give up your protections not to be balanced billed for these post-stabilization services.
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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. 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 have given written consent and give up your protections. You are never required to give up your protections 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.
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You are only responsible for paying your plan’s in-network cost-sharing amount. Your health plan will pay 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, 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, and count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
