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 health care 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 health care 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.

Under the federal “No Surprises Act” effective January 1st, 2022, healthcare providers must provide uninsured clients and/or clients who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services. This is intended to prevent clients from receiving surprise bills. You can ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service. This estimate of your costs is only an estimate and is based upon the information known at the time. Therefore, your actual charges may differ and does not include unknown or unexpected costs that may arise during treatment. This estimate of costs is not a contract and does not obligate you to obtain clinical services from me. I can provide you with referrals at your request.

You have the right to initiate the client-provider dispute resolution process if the charges you are actually billed substantially exceed the expected charges in this estimate. Specifically, if you receive a bill that is at least $400 more than your Good Faith Estimate. If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days from the date on the original bill. There is a $25 fee to use the dispute process. If the dispute-reviewing agency agrees with you, you will be responsible for the amount provided on your Good Faith Estimate. If the agency disagrees with your dispute and agrees with the fees charged by me that exceed the Good Faith Estimate, you will have to pay the higher amount charged.

To learn more visit www.cms.gov/nosurprises or call HHS at 1-877-696-6775.

“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 balanced 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 have been wrongly billed, please reach out to Micah Vacatio, MSW, LICSW immediately to discuss this issue and get it corrected.