Your Rights and Protections Against Surprise Medical Bills
For Services Rendered On or After January 1, 2022
Protection Against Surprise Medical Bills (the “No Surprises Act”)
Your Rights and Protections Against Surprise Medical Bills
If 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 under the No Surprise Act. In these cases, you should not be charged more than your plan’s copayments, coinsurance, and/or deductible.
What is “Out-of-Network”?
“Out-of-network” refers to 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.
What is “Balance Billing” (sometimes called “Surprise Billing)?
When you see a doctor or other healthcare provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, and/or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a healthcare facility that is not in your health plan's network.
“Surprise billing” occurs when you receive an unexpected balance bill. This can happen when you cannot 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 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 they can charge you is your plan's in-network cost-sharing amounts (such as copayments, coinsurance, and/or deductibles). You cannot be balance billed for these emergency services. This protection also extends to services you receive after you've been stabilized, unless you give written consent to waive these protections and agree to be balance billed for any post-stabilization care.
Certain services at an in-network hospital or ambulatory surgical center
When you receive services at an in-network hospital or ambulatory surgical center, some providers may still be out-of-network. In these cases, the most they can charge you is your plan’s in-network cost-sharing amount. This applies to providers offering emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These out-of-network providers cannot balance bill you, and they cannot ask you to waive your protections against balance billing for these services.
If you receive other types of services at in-network facilities, out-of-network providers still cannot balance bill you, unless you give written consent and agree to give up your protections.
You are never required to give up your protections against balance billing, nor are you required to choose out-of-network care. You always have the option to select a provider or facility within your health plan’s network.
When balance billing is not allowed, you are protected in the following ways:
- You are only responsible for paying your share of the cost, such as copayments, coinsurance, and/or deductibles—just like you would pay if the provider or facility were in-network. Your health plan will cover any additional costs directly to the out-of-network provider or facility.
- In general, your health plan must:
- Cover emergency services without requiring prior authorization (approval in advance).
- Cover emergency services provided by out-of-network providers.
- Calculate your cost-sharing based on what your plan would pay an in-network provider or facility, and show this 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.
Depending on the location where they are seen, state laws may provide additional balance billing protections. However, these protections only apply to health plans subject to state law. See the “Summary of State Surprise Bill and Balance Billing Protections” located below.
You have the right to receive a “good faith estimate” explaining how much your healthcare will cost.
Under the law, healthcare facilities and providers must give patients who do not have certain types of healthcare coverage or who are not using certain types of healthcare coverage an estimate of their bill for healthcare 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 healthcare 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 a healthcare item or service at least 3 business days in advance, make sure your healthcare provider or facility gives you a good faith estimate in writing within 1 business day after scheduling. If you schedule a healthcare item or service at least 10 business days in advance, make sure your healthcare provider or facility gives you a good faith estimate in writing within 3 business days after scheduling. You can also ask any healthcare provider or facility for a good-faith estimate before you schedule an item or service. If you do, make sure the healthcare provider or facility gives you a good-faith estimate in writing within 3 business days after you ask.
- If you receive a bill that is at least $400 more for any provider or facility than your good-faith estimate from that provider or facility, you can dispute the bill.
If you believe you’ve been wrongly billed, have questions, or would like more information about your right to a good faith estimate, visit cms.gov/medical-bill-rights or call 1-800-985-3059.
Summary of State Surprise Bill and Balance Billing Protections*
Alabama law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. For more information about your rights under Alabama law, visit https://www.cms.gov/medical-bill-rights
Alaska law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services.
Arizona law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services, in addition to a consumer dispute resolution process. For more information about your rights under Arizona law, visit difi.az.gov/soonbdr.
Arkansas law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. For more information about your rights under Arkansas law, visit https://insurance.arkansas.gov or call the No Surprise Help Desk at 800-985-3059.
California law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. In most circumstances, you cannot be charged more than your in-network cost share amount for emergency and non-emergency services. California also has a voluntary, non-binding dispute-resolution process for emergency services. For more information about your rights under California law, visit www.insurance.ca.gov.
Colorado law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. In most circumstances, you cannot be charged more than your in-network cost share amount for emergency and non-emergency services. For more information about your rights under Colorado law, visit www.doi.colorado.gov.
Connecticut law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. In most circumstances, you cannot be charged more than your in-network cost share amount for emergency services, and non-emergency services provided at in-network facilities. For more information about your rights under Connecticut law, visit www.portal.ct.gov/CID.
Delaware law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. In most circumstances, your health plan must hold you harmless for emergency services provided by out-of-network providers at out-of-network facilities. Providers also cannot balance bill you for non-emergency services provided at in-network facilities without obtaining your consent. For more information about your rights under Delaware law, visit www.insurance.delaware.gov.
Florida law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. In most circumstances, you cannot be charged more than your in-network cost share amount for emergency and non-emergency services. For more information about your specific rights under Florida law, visit www.floir.com/index.aspx.
Georgia law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. For more information about your specific rights under Georgia law, visit https://rules.sos.ga.gov/gac/120-2-106
Hawaii law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services.
Idaho law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. For more information about your specific rights under Idaho law, visit https://doi.idaho.gov/consumers/health-insurance/nosurprises/
Illinois law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. In most circumstances, you cannot be charged more than your in-network cost share amount for emergency and non-emergency services provided by out-of-network providers at in-network facilities. For more information about your rights under Illinois law, visit www2.illinois.gov/sites/Insurance.
Indiana law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. In most circumstances, you cannot be charged more than your in-network cost share amount for emergency services, and for non-emergency services provided at in-network facilities. For more information about your rights under Indiana law, visit www.in.gov/idoi/.
Iowa law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. For more information about your rights under Iowa law, visit https://iid.iowa.gov/legal-resources/legal-information/no-surprises-act/no-surprises-act-consumer-information
Kansas law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services.
Kentucky law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. For more information about your rights under Kentucky law, visit https://www.cms.gov/nosurprises
Louisiana law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services.
Maine law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. For more information about your rights under Maine law, visit https://legislature.maine.gov/statutes/22/title22sec1718-D-1.html
Maryland law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. In most circumstances, you cannot be charged more than your in-network cost share amount for emergency services, and for non-emergency services provided by out-of-network providers at in-network facilities. For more information about your rights under Maryland law, visit www.insurance.maryland.gov.
Massachusetts law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. In most circumstances, you cannot be charged more than your in-network cost share amount for emergency and non-emergency services provided by out-of-network providers at in-network facilities. For more information about your rights under Massachusetts law, visit www.mass.gov/orgs/division-of-insurance.
Michigan law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. In most circumstances, you cannot be charged more than your in-network cost share amount for emergency services, and for non-emergency services provided by out-of-network providers at in-network facilities. For more information about your rights under Michigan law, visit www.michigan.gov/difs.
Minnesota law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. In most circumstances, your plan must hold you harmless for amounts beyond your in-network cost share amount for non-emergency services provided by out-of-network providers at in-network facilities. For more information about your rights under Minnesota law, visit www.mn.gov/commerce/consumers/your-insurance.
Mississippi law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. In most circumstances, you cannot be charged more than your in-network cost share amount for emergency services, and for non-emergency services provided by out-of-network providers at in-network facilities. For more information about your rights under Mississippi law, visit www.mid.ms.gov/about/commissioner.aspx.
Missouri law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. In most circumstances, you cannot be charged more than your in-network cost share amount for emergency services provided by out-of-network providers at in-network facilities. For more information about your rights under Missouri law, visit www.insurance.mo.gov.
Montana law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. For more information about your rights under Montana law, visit https://csimt.gov
Nebraska law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. For more information about your rights under Nebraska law, visit https://doi.nebraska.gov/consumer/no-surprises-act-new-protection-surprise-balance-bills
Nevada law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. In most circumstances, your health plan must hold you harmless for amounts beyond your in-network cost share amount for emergency services provided by out-of-network providers and facilities. For more information about your rights under Nevada law, visit www.doi.nv.gov.
New Hampshire law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. For more information about your rights under New Hampshire law, visit https://www.insurance.nh.gov
New Jersey law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. In most circumstances, you cannot be charged more than your in-network cost share amount for emergency services, and for non-emergency services provided by out-of-network providers at in-network facilities. For more information about your rights under New Jersey law, visit www.state.nj.us/dobi/index.html.
New Mexico law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. In most circumstances, you cannot be charged more than your in-network cost share amount for emergency services, and for non-emergency services provided by out-of-network providers at in-network facilities. For more information about your rights under New Mexico law, visit www.newmexico.gov/category/other-affected-services/office-of-the-superintendent-of-insurance.
New York law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. For more information about your rights under New York law, visit https://www.dfs.ny.gov/consumers/health_insurance/protections_federal_no_surprises_act
North Carolina law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. In most circumstances, your health plan must hold you harmless for amounts beyond your in-network cost share amount for emergency services provided by out-of-network providers. For more information about your rights under North Carolina law, visit www.ncdoi.gov.
North Dakota law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. For more information about your rights under North Dakota law, visit https://www.insurance.nd.gov
Ohio law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. In most circumstances, your health plan must hold you harmless for amounts beyond your in-network cost share amount for emergency services by out-of-network providers, facilities, and ground ambulance service providers, and for non-emergency services by out-of-network providers at in-network facilities. For more information about your rights under Ohio law, visit www.insurance.ohio.gov.
Oklahoma law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. For more information about your rights under Oklahoma law, visit https://www.oid.ok.gov/nsa/
Oregon law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. In most circumstances, you cannot be charged more than your in-network cost share amount for emergency services, and for non-emergency services provided by out-of-network providers at in-network facilities. For more information about your rights under Oregon law, visit www.dfr.oregon.gov/Pages/index.aspx.
Pennsylvania law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. In most circumstances, your plan must hold you harmless for amounts beyond your in-network cost share amount for emergency services. For more information about your rights under Pennsylvania law, visit www.insurance.pa.gov.
Rhode Island law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. For more information about your rights under Rhode Island law, visit https://dbr.ri.gov/insurance-overview
South Carolina law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. For more information about your rights under South Carolina law, visit https://www.doi.sc.gov/1001/No-Surprises-Act-Information
South Dakota law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. For more information about your rights under South Dakota law, visit https://dlr.sd.gov/insurance/no_surprises_act.aspx
Tennessee law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. For more information about your rights under Tennessee law, visit https://www.tn.gov/commerce/blog/2022/1/12/the-no-surprises-act-will-protect-tennessee-consumers.html
Texas law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. In most circumstances, you cannot be charged more than your in-network cost share amount for emergency services, and for non-emergency services provided by out-of-network providers at in-network facilities. For more information about your rights under Texas law, visit www.tdi.texas.gov.
Utah law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. For more information about your rights under Utah law, visit https://insurance.utah.gov/consumers/health-insurance/no-surprises-act/
Vermont law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. For more information about your rights under Vermont law, visit https://dfr.vermont.gov/no-surprises-act#:~:text=A%20measure%20included%20in%20the,against%20certain%20surprise%20medical%20bills.
Virginia law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. For more information about your rights under Virginia law, visit https://www.scc.virginia.gov/consumers/insurance/health-insurance-consumer/balance-billing-protection/
Washington law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. In most circumstances, you cannot be charged more than your in-network cost share amount for emergency services, and for non-emergency services provided by out-of-network providers at in-network facilities. For more information about your rights under Washington law, visit www.insurance.wa.gov.
West Virginia law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. For more information about your rights under West Virginia law, visit https://www.wvinsurance.gov/no_surprises_act
Wisconsin law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. For more information about your rights under Wisconsin law, visit https://oci.wi.gov/pages/consumers/nosurprisesact.aspx
Wyoming law protects consumers from unexpected medical bills and against balance billing for certain out-of-network emergency and non-emergency services. For more information about your rights under Wyoming law, visit https://doi.wyo.gov
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