When you get emergency care or are treated by an out-of-network doctor 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 deductible.
Surprise Billing Protection Notice
Your Rights and Protections Against Surprise Medical Bills
Effective January 1, 2022.
Effective January 1, 2022.
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 doctor or visit a healthcare facility that isn't in your health plan's network.
"Out-of-network" means doctors and facilities that haven't signed a contract with your health plan to provide services. Out-of-network doctors may be allowed to bill you for the difference between what your plan pays and the total 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 plan's deductible or 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 schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network doctor. Depending on the procedure or service, surprise medical bills could cost thousands of dollars.
You're protected from balance billing for:
Emergency services
If you have an emergency medical condition and get emergency services from an out-of-network doctor or facility, the most they can bill you is your plan's in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). 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
Certain doctors may be out-of-network when you get services from an in-network hospital or ambulatory surgical center and certain doctors may be out-of-network. In these cases, the most those doctors 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 to not be billed.
If you get other types of 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 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 (like the copayments, coinsurance and deductible that you would pay if the doctor or facility were in-network). Your health plan will directly pay any additional costs to out-of-network doctors and facilities directly.
- Generally, your health plan must:
- Cover emergency services without requiring you to get approval for services in advance (also known as "prior authorization").
- Cover emergency services by out-of-network doctors.
- Base what you owe the doctor or facility (cost-sharing) on what it would pay an in-network doctor 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 in-network deductible and out-of-pocket limit.
If you think you've been wrongly billed, you may contact the Centers for Medicare & Medicaid Services at 1.800.985.3059 or the Massachusetts Department of Public Health at 617.624.6000.
Visit www.cms.gov/nosurprises for more information about your rights under federal law.