Balance Billing Protection

Your Rights and Protections Against Surprise Medical Bills

When you receive emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you should not be charged more than your plan’s copayments, coinsurance and/or deductible.

What is balance billing/surprise billing?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance or deductible. You may have additional 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" refers to providers and facilities that have not 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 pays 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 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 when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills can cost thousands of dollars depending on the procedure or service.

You are protected from balance billing for:

• Emergency services

  If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, 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.

  Florida law also provides some protection for balance billing. If your insurance* provider is from Florida, then you can’t be balance billed for emergency services. You are only responsible for paying your copay, deductible and coinsurance.

• 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 there may be out-of-network. In these cases, the most those providers can 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 types of 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 are never required to give up your protections from balance billing. You also are not required to get out-of-network care. You can choose a provider or facility in your plan’s network.

Also, Florida law doesn’t allow providers to balance bill for other services covered by your insurance for non-emergency visits if you are part of a Healthcare Management Organization, or HMO, from Florida. If you are in a Preferred Provider Organization* from the state of Florida, or PPO, then Florida law provides you protections as well. You can’t be balanced billed when you are at a provider who is out-of-network if you didn’t have a choice who treated you.

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

• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
• 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 you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

You Have the Right to Receive a Good Faith Estimate

Explaining How Much Your Health 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 their bill for health care items and services before those items or services are provided.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services upon request or when scheduling such items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
• If you schedule an item or service at least three business days in advance, make sure your health care provider gives you a Good Faith Estimate in writing within one business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, make sure your health care provider gives you a Good Faith Estimate in writing within three business days after scheduling. You can also ask any health care provider for a Good Faith Estimate before you schedule an item or service. If you do, make sure the healthcare provider gives you a Good Faith Estimate in writing within three business days after you ask.
• 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 and the bill.

If you think you have been wrongly billed, contact No Surprises Help Desk at (800) 985-3059 or email us at FederalPPDRQuestions@cms.hhs.gov.

Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.

*Florida law does not apply to insurance plans from other states or employer-owned insurance plans. Federal law does provide protection for those.