Your rights and protections against surprise medical bills

Your Rights and Protections Against Surprise Medical Bills
When you obtain emergency care or are 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”)?
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:
EMERGENCY SERVICES
If you have an emergency medical condition and receive 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 and coinsurance). You cannot be balance billed for these emergency services. This includes services you may receive 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.

See a summary of related state balance billing laws at: https://www.commonwealthfund.org/publications/maps-and-interactives/2021/feb/state-balance-billing-protections.

CERTAIN SERVICES AT AN IN-NETWORK HOSPITAL OR AMBULATORY SURGICAL CENTER
When you obtain 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 cannot balance bill you and may not ask you to give up your protections not to be balance billed.

If you obtain other services at these in-network facilities, out-of-network providers cannot balance bill you, unless you give written consent and give up your protections.

You are never required to give up your protections from balance billing. Also, you are not required to obtain care out- of-network. You can choose a provider or facility in your plan’s network.

In certain states, you may also have related state protections:
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.

Visit The Commonwealth Fund website for updated state balance-billing protections at https://www.commonwealthfund.org/publications/maps-and-interactives/2021/feb/state-balance-billing-protections.

Applicable state balance billing laws or requirements for noted states are as follows:


ARIZONA PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• Above protection applies:
  • To HMO and PPO enrollees
  • For (1) emergency services provided by out-of-network professionals at in-network facilities and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• State provides a dispute resolution process for claims over $1000, which must be initiated by the enrollee
• Protections do not apply to:
  • ground ambulance services
  • services at out-of-network facilities
  • enrollees who consent to non-emergency out-of-network services
  • enrollees of self-funded plans

CALIFORNIA PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • For (1) emergency services by out-of-network professionals and facilities and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• State provides a payment standard
• Protections do not apply to:
  • ground ambulance services
  • enrollees who consent to non-emergency out-of-network services
  • enrollees in self-funded plans

COLORADO PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing Above protections apply
  • To HMO and PPO enrollees
  • For (1) emergency services provided by out-of-network professionals, facilities, and ground ambulance service providers and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care providers
• State provides a payment standard
• Protections do not apply:
  • to enrollees who consent to out-of-network non-emergency services
  • to enrollees of self-funded plans

CONNECTICUT PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • For (1) emergency services and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• State provides a payment standard
• Protections do not apply to:
  • ground ambulance services
  • out-of-network facility charges for emergency services
  • enrollees who consent to non-emergency out-of-network services
  • enrollees of self-funded plans

DELAWARE PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for emergency services provided
  • by out-of-network professionals
  • at out-of-network facilities
  • by certain out-of-network ground ambulance service providers
• State prohibits providers from balance billing enrollees for non-emergency services provided at in-network facilities unless they obtain consent from the enrollee
• Above protections apply to:
  • HMO and PPO enrollees
  • For services provided by all or most classes of health care professionals
• State provides a payment standard for emergency services
• State provides the option of arbitration
• Protections do not apply to:
  • enrollees who consent to non-emergency out-of-network services
  • enrollees in self-funded plans

FLORIDA PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • For (1) emergency services by out-of-network professionals and facilities and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• For PPOs, state payment standard applies to (1) emergency services and (2) non-emergency services provided by out-of-network professionals at in-network facilities
• For HMOs, state payment standard only applies to emergency services but the state also has a claim dispute resolution program in place
• Protections do not apply to:
  • ground ambulance services for PPO enrollees
  • PPO enrollees who consent to non-emergency out-of-network services
  • enrollees of self-funded plans

GEORGIA PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • For (1) emergency services by out-of-network professionals and facilities and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• State provides a payment standard for professionals but not facilities
• State provides a dispute resolution process
• Protections do not apply to:
  • ground ambulance services
  • enrollees who consent to non-emergency out-of-network services
  • enrollees in self-funded plans

ILLINOIS PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • For (1) emergency services provided by out-of-network professionals at in-network facilities, and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by certain specific classes of health care professionals
• State provides a dispute resolution process
• Protections do not apply to:
  • ground ambulance services
  • services received at out-of-network facilities
  • enrollees who consent to non-emergency out-of-network services
  • enrollees of self-funded plans

INDIANA PROTECTIONS AVAILABLE

• For HMOs, with respect to emergency services provided by out-of-network professionals and facilities, state (1) requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing; and (2) prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• For HMOs and PPOs, with respect to non-emergency services provided by out-of-network professionals at in- network facilities, state prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing. This prohibition applies to all providers in the state, and therefore might also protect enrollees of self-funded plans.
• Above protections apply to services provided by all or most classes of health care professionals.
• Protections do not apply to:
  • ground ambulance services
  • enrollees who consent to non-emergency out-of-network services

IOWA PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• Above protection applies:
  • To HMO and PPO enrollees
  • For emergency services provided by out-of-network professionals and facilities
  • Provided by all or most classes of health care professionals
• Protections do not apply to:
  • enrollees of self-funded plans
  • non-emergency services

MAINE PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • To enrollees of self-funded plans that have opted into the protections
  • For (1) emergency services by out-of-network professionals, facilities and ambulance providers; and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of out-of-network health care professionals
• State provides a payment standard
• Protections do not apply to enrollees who consent to out-of-network non-emergency services

MASSACHUSETTS PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• Above protection applies:
  • To HMO and PPO enrollees
  • For (1) emergency services provided by out-of-network professionals at in-network facilities, and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of out-of-network health care professionals
• Protections do not apply to:
  • ground ambulance services
  • services at out-of-network facilities
  • enrollees who consent to out-of-network services
  • enrollees of self-funded plans

MARYLAND PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To (1) emergency services provided by out-of-network professionals, facilities, and ambulance providers; and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all types of out-of-network health care professionals for HMO enrollees
  • Provided by on-call or hospital-based physicians who agree to accept assignment of benefits for PPO enrollees
• State provides a payment standard
• Protections do not apply to enrollees in self-funded plans

MICHIGAN PROTECTIONS AVAILABLE

• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • For (1) emergency services by out-of-network professionals and facilities; and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of out-of-network health care professionals
• State provides a payment standard
• State provides a dispute resolution process
• Protections do not apply to:
  • ground ambulance services
  • enrollees who consent to non-emergency out-of-network services
  • enrollees in self-funded plans

MINNESOTA PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• Above protection applies:
  • To HMO and PPO enrollees
  • For non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of out-of-network health care professionals
• State provides a dispute resolution process
• Protections do not apply to:
  • emergency services
  • enrollees of self-funded plans

MISSISSIPPI PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • For (1) emergency services by out-of-network professionals and facilities, and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• Protections do not apply to:
  • ground ambulance services
  • enrollees of self-funded plans

MISSOURI PROTECTIONS AVAILABLE

• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protection applies to:
  • To HMO, PPO, and EPO enrollees
  • For emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• State provides dispute resolution process
• Protections do not apply to:
  • ground ambulance services
  • services provided at out-of-network facilities
  • non-emergency services
  • enrollees of self-funded plans

NEBRASKA PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network professionals and facilities from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • For emergency services
  • Provided by all or most classes of health care professionals
• Protections do not apply to:
  • ground ambulance services
  • non-emergency services
  • enrollees of self-funded plans
• sState provides a payment standard

NEVADA PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply
  • To HMO and PPO enrollees
  • To enrollees of self-funded plans that have opted into the protections
  • For emergency services by out-of-network professionals and facilities
  • Provided by all or most classes of health care providers
• State provides a dispute resolution process
• Protections do not apply to:
  • ground ambulance services
  • non-emergency services

NEW HAMPSHIRE PROTECTIONS AVAILABLE

• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protection applies:
  • To any network-based major medical health insurance product, including HMO, PPO, EPO and POS products
  • For (1) emergency services provided by out-of-network professionals at in-network facilities, and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by certain specific classes of health care professionals
• State provides a dispute resolution process
• Protections do not apply to:
  • ground ambulance services
  • services at out-of-network facilities
  • enrollees of self-funded plans

NEW JERSEY PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO, PPO, EPO and POS enrollees
  • To enrollees of self-funded plans that have opted into the protections
  • For (1) emergency services provided by out-of-network professionals and facilities, and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• State provides a dispute resolution process
• Protections do not apply to:
  • ground ambulance services
  • enrollees who consent to non-emergency out-of-network services

NEW MEXICO PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • For (1) emergency services by out-of-network professionals and facilities and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• State provides a payment standard
• Protections do not apply to:
  • ground ambulance services
  • enrollees who consent to out-of-network non-emergency services
  • enrollees of self-funded plans

NEW YORK PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO, PPO and EPO enrollees.
  • For (1) emergency services provided by out-of-network facilities, professionals, and ground ambulance providers; and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• State provides a dispute resolution process
• Protections do not apply to
  • enrollees who consent to non-emergency out-of-network services†
  • enrollees of self-funded plans

NORTH CAROLINA PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • For emergency services by out-of-network professionals
  • Provided by all or most classes of health care professionals
• Protections do not apply to:
  • ground ambulance services
  • emergency services by out-of-network facilities o non-emergency services
  • enrollees of self-funded plans

OHIO PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• Above protection applies:
  • To HMO and PPO enrollees
  • For (1) emergency services provided by out-of-network professionals, facilities, and ground ambulance service providers and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by those classes of health care professionals as defined by regulation
• State provides a payment standard
• State provides a dispute resolution process
• Protections do not apply to:
  • enrollees of self-funded plans
  • enrollees who consent to out-of-network non-emergency services

OREGON PROTECTIONS AVAILABLE

• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protection applies:
  • To HMO and PPO enrollees
  • For (1) emergency services provided by out-of-network professionals at in-network facilities, and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• State provides a payment standard
• Protections do not apply to:
  • ground ambulance services
  • services at out-of-network facilities
  • enrollees who consent to non-emergency out-of-network services
  • enrollees of self-funded plans

PENNSYLVANIA PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• Above protection applies:
  • To HMO and PPO enrollees
  • For emergency services
  • Provided by all or most classes of health care professionals
• Protections do not apply to:
  • ground ambulance services
  • out-of-network facility emergency service charges, for PPO enrollees only
  • non-emergency services
  • enrollees of self-funded plans
  
  
  

RHODE ISLAND PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• Above protection applies:
  • To HMO enrollees
  • For (1) emergency services, and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• Protections do not apply to:
  • PPO enrollees
  • ground ambulance services
  • enrollees of self-funded plans

TEXAS PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO, PPO, and EPO enrollees
  • For (1) emergency services by out-of-network professionals and facilities, and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• State provides dispute resolution process
• Protections do not apply to:
  • ground ambulance services
  • enrollees who consent to out-of-network non-emergency services
  • enrollees of self-funded plans

VERMONT PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• Above protection applies:
  • To HMO and PPO enrollees
  • For emergency services including ground ambulance services
  • Provided by all or most classes of health care professionals
• Protections do not apply to:
  • out-of-network facility charges for emergency services
  • non-emergency services
  • enrollees of self-funded plans

VIRIGINA PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • To enrollees of self-funded plans that have opted into the protections
  • For (1) emergency services by out-of-network professionals and facilities, and (2) non-emergency surgical or ancillary services provided by all or most classes of out-of-network professionals at in-network facilities
• State provides a dispute resolution process
• Protections do not apply to ground ambulance services

WASHINGTON STATE PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • To enrollees of self-funded plans that have opted into the protections
  • For (1) emergency services provided by all or most classes of health care professionals and out-of-network facilities and (2) non-emergency surgical or ancillary services provided by all or most classes of out-of- network professionals at in-network facilities
• State provides a dispute resolution process
• Protections do not apply to ground ambulance services

WEST VIRGINIA PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• Above protection applies:
  • To HMO enrollees
  • For emergency services including ground ambulance services
  • Provided by all or most classes of health care professionals
• Protections do not apply to:
  • out-of-network facility charges for emergency services
  • non-emergency services
  • enrollees of self-funded plans

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:

Visit https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/no-surprises-act for more information about your rights under federal law.

Visit https://www.commonwealthfund.org/publications/maps-and-interactives/2021/feb/state-balance-billing-protections for more information about your rights under your state laws.