Your Rights and Protections Against Surprise Medical Bills

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

What is “surprise billing” (also called “balance 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” 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 for the difference between what your plan pays and the full amount charged for a service. This is called “surprise billing” or "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
could cost thousands of dollars depending on the procedure or service.

 

You’re protected from surprise or 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 surprise/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 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 surprise/balance bill you and may not ask you to give up your protections not to be surprised/balance billed.

If you get other types of services at these in-network facilities, out-of-network providers can’t surprise/balance bill you, unless you give written consent and give up your protections.
 

You are never required to give up your protections from surprise/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.
 

Additional protections related to non-emergency services delivered by an out-of-network provider at an in-network facility also may be available to you under Massachusetts law depending on your insurance plan. If the protections under Massachusetts law apply to you, your providers must disclose whether or not they are in your plan’s network upon scheduling a service or at your request. If a provider is not in your plan’s network, the provider must provide you with information on its charges, your estimated out-of-pocket costs including any facility fees, and inform you that you may be able to obtain the services at a lower cost through an in-network provider. If a provider does not make these required disclosures to you in advance, the provider cannot balance bill you. These protections under Massachusetts law do not apply to you if you are enrolled in an employer self-funded health insurance plan.
 

When surprise/balance billing is not 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.

If you think you’ve been wrongly billed, you may contact the No Surprises Help Desk at 1-800-985-3059 or the Massachusetts Attorney General’s Office at 888-830-6277.

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

 

Joslin Diabetes Center is part of the Beth Isreal Lahey Health system.