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”)?
You are protected from balance billing for:
Upon scheduling an appointment for nonemergency medical services, or at your request, your health care provider must disclose whether they participate in your health insurance plan (and must update you if this information changes during the course of your treatment). If your provider participates in your health insurance plan, the provider has to inform you of your right to request disclosure of the allowed amount and facility fee(s) (or an estimate of the maximum allowed amount and fees), and inform you how to obtain information regarding any applicable out-of-pocket costs. If your provider does not participate in your health insurance plan, the provider must provide the charge amount, any facility fees for your service, advise you of your potential financial liability for any non covered services, and inform you that you may be able to receive care at a lower cost from a provider that participates in your health insurance plan.
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 directly.
- 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 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 you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact the Department of Health and Human Services at 1-877-696-6775 or the Massachusetts Department of Health at 617-624-6000.
Visit https://www.cms.gov/nosurprises/consumers for more information about your rights under federal law.