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 balance billing. In these cases, you shouldn't be charged more than your plan's copayments, coinsurance, and/or deductible.

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, 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. This is called "balance billing." "Surprise billing" is an unexpected balance bill, which can happen when you can't control who is involved in your care.

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. You can't be balance billed for these services, including services you may get after you're in stable condition, unless you give written consent and give up your protections.

Certain services at an in-network hospital or ambulatory surgical center. Some providers there may be out-of-network. In these cases, the most they 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. If you get other services at these facilities, out-of-network providers can't balance bill you unless you give written consent.

You're never required to give up your protections from balance billing. You also aren't required to get out-of-network care. You can choose a provider or facility in your plan's network.

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

• You're only responsible for paying your share of the cost (copayments, coinsurance, and deductibles) that you would pay if the provider or facility was in-network. Your health plan will pay any additional costs directly.
• Your health plan generally must cover emergency services without prior authorization, cover emergency services by out-of-network providers, base what you owe on in-network rates, and count amounts you pay for emergency or out-of-network services toward your in-network deductible and out-of-pocket limit.

Good Faith Estimate for uninsured or self-pay patients

You have the right to receive a Good Faith Estimate explaining how much your medical care will cost. If you don't have insurance or are not using insurance, health care providers must give you an estimate of the expected charges for items and services, including related costs such as tests and supplies.

• You can ask for a Good Faith Estimate when you schedule a service or at any time before. Make sure your provider gives you one in writing at least 1 business day before your service if scheduled 3 or more business days ahead.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
• Keep a copy of your Good Faith Estimate.

Questions or complaints

If you believe you've been wrongly billed, contact the No Surprises Help Desk at 1-800-985-3059 or visit cms.gov/nosurprises. Virginia residents may also contact the Virginia Bureau of Insurance at 1-877-310-6560 or visit scc.virginia.gov.