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. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductibles.
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 copayments, coinsurance and/or deductibles. 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 to provide services. Out-of-network providers may be allowed 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. Surprise medical bills could cost thousands of dollars depending on the procedure or service.
Your protections from balance billing
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, coinsurance and/or deductibles). 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.
Prior to the passage of the federal No Surprises Act, some states enacted certain, more limited balance billing protections, including:
Certain services at an in-network hospital or ambulatory service 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 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 protections from balance billing. You also aren’t required to get care out of network. You can choose a provider or facility in your plan’s network.
Additional protections when balance billing isn’t allowed
You’re only responsible for paying your share of the cost (like the copayments, coinsurance and/or deductibles you would pay if the provider or facility were in network). Your health plan will pay any additional costs 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 (also known as prior authorization)
- Cover emergency services by out-of-network providers
- Base what you owe the provider or facility (also known as cost sharing) on what the plan would pay an in-network provider or facility, and show that amount in your Explanation of Benefits
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit
If you think you’ve been wrongly billed
Contact the No Surprises Help Desk at