Your Right and Protections Against Surprise Medical Bills
You are protected from balance billing when you get emergency care or treated by an out-of-network provider at an in-network hospital or ambulatory surgical center. In these cases, you shouldn’t be charged more than your plan’s copayments coinsurance, 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 copayment, coinsurance, or deductible. You may have additional costs or 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” 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 the difference between what your plan pays and the total 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 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 are protected from balance billing for:
Suppose you have an emergency medical condition and get emergency services from an out-of-network provider or facility. In that case, the most they can bill you is your 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 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.
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 may be out-of-network. In these cases, the most those providers can bill you in 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 to be balanced 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 protection from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have these protections:
- You’re only responsible for paying your share of the cost (like the copayments, coinsurance and deductible that you would pay if the provider or facility were in-network).Your health plan will pay any additional costs directly to out-of-network providers and facilities.
- Generally, your health plan 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 (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
- Count any amount of pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit
If you think you’ve been wrongly billed, contact Excelsior Orthopaedics at 716-250-6401. The federal phone number for information and complaints is 1-800-985-3059 or visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.