Your Rights and Protections from Unexpected Medical Charges
If you receive emergency medical care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgery center, certain laws shield you from unexpected or “balance” billing.

What is Balance Billing (Also Known as Surprise Billing)?
When you visit a doctor or healthcare provider, you typically pay a portion of the bill—such as a deductible, copay, or coinsurance. However, if the provider or facility isn’t part of your insurance network, you might be charged additional amounts—or even the full cost—of the service.

“Out-of-network” means the provider or facility has no contract with your health insurance plan. In those cases, they might bill you for the difference between their total charges and what your insurance is willing to pay. This is referred to as balance billing, and these charges are often higher than those from in-network providers. These bills may not count toward your yearly out-of-pocket maximum.

A surprise bill occurs when you’re unexpectedly treated by an out-of-network provider—often without your knowledge—such as during emergencies or at in-network facilities where some staff may not participate in your plan.

Protections You Have Against Balance Billing

Emergency Care
If you require emergency services and receive care from an out-of-network hospital or provider, you cannot be billed more than your insurance plan’s in-network cost-sharing amount (like copays or coinsurance). Balance billing is not permitted for these emergency services. This includes care you receive once you are stabilized—unless you sign a consent form allowing the provider to bill you beyond your insurance limits.

Services at In-Network Hospitals or Surgical Centers
Even when treated at an in-network hospital or ambulatory surgical center, certain staff (such as anesthesiologists, radiologists, or pathologists) may be out-of-network. In such cases, you can only be billed the in-network rate for those services. This protection applies to:
● Emergency medicine
● Anesthesia
● Pathology
● Radiology
● Laboratory services
● Neonatology
● Assistant surgeons
● Hospitalists
● Intensivists

These providers are prohibited from balance billing you and may not request that you waive your protections.

If you receive non-emergency services at an in-network facility from an out-of-network provider, they can only balance bill you if you sign a written agreement consenting to it.

You are never obligated to waive your rights. Additionally, you’re not required to use an out-of-network provider—you always have the option to choose an in-network facility or provider.

Additional Safeguards When Balance Billing is Not Allowed
● You are only responsible for standard in-network cost-sharing, such as deductibles, coinsurance, and copayments.
● Your insurance plan must:
○ Provide emergency care coverage without prior authorization.
○ Pay for emergency services from out-of-network providers.
○ Base your costs on in-network rates and reflect those figures in your Explanation of Benefits (EOB).
○ Apply your payments for out-of-network or emergency care toward your deductible and out-of-pocket maximum.

Many states have specific rules for how insurers pay out-of-network providers. If no state regulation applies—or if you believe you’ve been billed incorrectly—you can file a complaint or ask for help by calling the federal No Surprises Help Desk at 1-800-985-3059.

To learn more about your rights under federal law, visit:
https://www.cms.gov/nosurprises/consumers