Understanding Balance Billing and Surprise Billing

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 such situations, your financial responsibility is limited to your health plan’s standard cost-sharing amounts, such as copayments, coinsurance, and deductibles. You cannot be billed for additional charges beyond these amounts.

What is Balance Billing?
Balance billing, sometimes referred to as “surprise billing,” occurs when you receive care from a healthcare provider or facility that is out-of-network for your health insurance plan. This means the provider or facility has not signed a contract with your insurance company. In such cases, you may be billed for the difference between what your health plan pays and the full cost of the service. This amount is typically higher than in-network costs and may not count toward your plan’s deductible or annual out-of-pocket maximum.

What is Surprise Billing?
Surprise billing happens when you receive an unexpected balance bill, often in situations where you cannot choose your provider, such as:

  • Emergency situations, where you are taken to an out-of-network facility or treated by an out-of-network provider.
  • Scheduled visits at in-network facilities, where you unexpectedly receive care from an out-of-network provider (e.g., an anesthesiologist or radiologist).

Surprise medical bills can amount to thousands of dollars, depending on the services provided.

Protections Against Balance Billing and Surprise Billing

You are protected from balance billing in the following scenarios:

  1. Emergency Services
    • If you receive emergency care from an out-of-network provider or facility, they may only bill you for your in-network cost-sharing amount (e.g., copayments, coinsurance, or deductibles).
    • This protection also extends to post-stabilization services unless you provide written consent to waive it.
  2. Certain Services at In-Network Facilities
    • If you receive care at an in-network hospital or ambulatory surgical center, certain providers (e.g., anesthesiologists, radiologists, or pathologists) who may be out-of-network can only bill you for in-network cost-sharing amounts.
    • You cannot be asked to waive these protections unless you give written consent.

Key Consumer Rights

When balance billing is prohibited, you are entitled to the following protections:

  • Limited Out-of-Pocket Costs: You are only responsible for your in-network cost-sharing amount. Your health plan will pay any additional costs to out-of-network providers or facilities.
  • Emergency Services Coverage: Your health plan must:
    • Cover emergency services without requiring prior authorization.
    • Cover emergency care from out-of-network providers.
    • Base your cost-sharing amount on what you would pay for in-network services and reflect this in your explanation of benefits.
    • Count payments for emergency or out-of-network services toward your in-network deductible and out-of-pocket limits.

Steps to Take if You Encounter Balance Billing

  • Check State Laws: Some states provide additional protections against balance billing. Contact your State Department of Insurance to learn more.
  • Federal Protections: If no state law applies or you believe you were wrongly billed, contact federal regulators for assistance at 1-800-985-3059.
  • For more information about your rights under federal law, visit the No Surprises Act consumer page.