Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
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, such as a copayment, coinsurance and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a healthcare facility that isn’t in your health plan’s network.
“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 providersand facilities.
- Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (priorauthorization).
- Cover emergency services by out-of-network
- 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
- 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 419-630-2149 to speak with a billing representative. Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law. Visit www.insurance.ohio.gov/strategic-initiatives/surprise-billing for more information about your rights under Ohio laws.
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 don’t intend to use insurance to pay for scheduled non-emergency healthcare services, healthcare providers and facilities must provide you with an estimate of expected charges before you get an item or service.
- Providers and facilities must provide you with a good faith estimate if you request one, or after you’ve scheduled an item or service.
- The estimate should include expected charges for the primary item or service you’re getting, and any other items or services that are provided as part of the same scheduled experience.
Providers and facilities must provide the good faith estimate before an item or service is scheduled, within certain timeframes. This includes:
- An itemized list of each item or service, grouped by the provider or facility offering care. Each item or service has to have specific details, like the healthcare code assigned to it and the expected charge.
- Explaining the good faith estimate to you over the phone or in-person if you request it, and then a follow-up with a written (paper or electronic) estimate.
- Providing the good faith estimate in a way that’s accessible to you.
Once you receive a good faith estimate from your provider or facility, be sure to keep it in a safe place so you can compare it to any bills you get later.
- If you’ve had your service and find that the billed amount is at least $400 above the good faith estimate, you can dispute the bill.
For questions or more information about your right to a good faith estimate, call the Parkview Utilization Review Department at 419-737-4645, visit www.cms.gov/nosurprises/consumers or call 1-800-985-3059.