No Surprise Act

Your rights & 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 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.

You are protected from balance billing for:

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.

Certain services at an in-network hospital or ambulatory surgical center

When you receive care at an in-network hospital or ambulatory surgical center, some providers may be out of network. For services such as emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgery, hospitalist or intensivist care, you’ll pay no more than your in-network cost-sharing amount. These providers cannot balance bill you or ask you to waive your balance billing protections.

Emergency services

If you receive emergency care from an out-of-network provider or facility, you’ll pay no more than your plan’s in-network cost-sharing amount. You cannot be balance billed for emergency services, including most care you receive after you're stable, unless you provide written consent to waive those protections.

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.

When balance billing isn’t allowed, you also have the following protections:

You are only responsible for your share of the cost, such as copayments, coinsurance and deductibles, as if the provider or facility were in network.

Your health plan generally must:

• Pay out-of-network providers and facilities directly.
• Cover emergency services without requiring prior authorization.
• Cover emergency services provided by out-of-network providers.
• Base your cost-sharing on what it would pay an in-network provider or facility and include that amount in your Explanation of Benefits (EOB).
• Apply amounts you pay for emergency or eligible out-of-network services toward your deductible and out-of-pocket maximum.

Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

• Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, contact Roper St. Francis Customer Service at (888) 472-0042 or CMS at (800) 985-3059.