“Out-of-network” describes 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.
“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.
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 the provider or facility may bill you is your plan’s in-network cost sharing amount (such as copayments and coinsurance). You can’t be 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 may 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 not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have the following protections:
- You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in network).Your health plan will pay out-of-network providers and facilities directly.
- Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (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 deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact the No Surprises Help Desk at 1-800-985-3059 from 8 am to 8 pm EST, 7 days a week, to submit your question or a complaint. Or, you can submit a complaint online: https://www.cms.gov/nosurprises/consumers/complaintsabout-medical-billing. You may be asked to provide supporting documentation like medical bills and your Explanation of Benefits. You’ll receive a confirmation email when your complaint is received to notify you of next steps, and let you know if any additional information is needed. To check on the status of a complaint, or to see what documentation is needed, contact the No Surprises Help Desk at the number listed above.
If you submit a request, what can the Centers for Medicare and Medicaid Services (CMS) do?
What can the Centers for Medicare and Medicaid Services (CMS) do?
- Require medical providers or health care facilities to adjust their charges.
- Act as your lawyer or give you legal advice.
- Make medical judgments or determine if further treatment is necessary.
- Determine the value of a claim, or the amount owed to you.
- Address issues CMS can’t legally enforce.
If you still need help with your health insurance and have a problem or question, contact your state Consumer Assistance Program. These programs help consumers experiencing problems with their health insurance or seeking to learn about health coverage options.
- Call the No Surprises Help Desk at 1-800-985-3059.
- Get help in a language other than English. Information about how to access these services is available through the No Surprises Help Desk.
- Call the No Surprises Help Desk to get this information in an accessible format, like large print, Braille, or audio, at no cost to you.
- Visit https://www.cms.gov/nosurprises/consumers for more information about your rights under federal law.
- For a digital version of this document or to learn more, please visit https://www.mvhealth.org/financial-assistance/
If you have any further questions regarding this notice, you may contact Jerri Dion at (509) 826-7638 or by email: DionJ@mvhealth.org.
