Rights Regarding Medical Bills

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 in accordance with the Federal No Surprises Act (NSA). The protections of the NSA apply to your health plan on the first plan year beginning on and after 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, 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.

“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 are covered under a state-regulated health plan or receive care in one of the states listed below, state laws may offer additional protections against balance billing. If you believe you have been wrongly billed, you may contact the relevant state agency:

Arizona: AZ Department of Insurance & Financial Institutions at 602-364-3100.
California: CA Department of Managed Health Care at 1-888-466-2219 or CA Department of Insurance at 1-800-927-4357.
Colorado: CO Division of Insurance at 1-800-930-3745.
Connecticut: CT Insurance Department at 1-800-203-3447 or CT Office of the Healthcare Advocate at 1-866-466-4446.
Florida: FL Office of Insurance Regulation / CFO Consumer Services at 1-877-693-5236.
Idaho: ID Department of Insurance at 1-800-721-3272.
Illinois: IL Department of Insurance at 1-866-445-5364.
Indiana: IN Department of Insurance at 1-800-622-4461.
Kentucky: KY Department of Insurance at 1-800-595-6053.
Maine: ME Bureau of Insurance at 1-800-300-5000.
Massachusetts: MA Division of Insurance at 1-877-563-4467.
Michigan: MI Department of Insurance and Financial Services at 1-877-999-6442.
Nevada: NV Division of Insurance at 1-888-872-3234.
New Hampshire: NH Insurance Department at 1-800-852-3416.
New Jersey: NJ Department of Banking and Insurance at 1-800-446-7467.
New York: NY Department of Financial Services at 1-800-342-3736.
North Carolina: NC Department of Insurance at 1-855-408-1212.
Ohio: OH Department of Insurance at 1-800-686-1526.
Oklahoma: OK Insurance Department at 1-800-522-0071.
Pennsylvania: PA Insurance Department at 1-877-881-6388.
Rhode Island: RI Office of the Health Insurance Commissioner at 1-855-747-3224.
South Carolina: SC Department of Insurance at 1-800-768-3467.
Tennessee: TN Department of Commerce & Insurance at 1-800-342-4029.
Texas: TX Department of Insurance Consumer Help Line at 1-800-252-3439.
Utah: UT Insurance Department at 1-800-439-3805.
Vermont: VT Department of Financial Regulation at 1-800-964-1784.
Virginia: VA State Corporation Commission Bureau of Insurance at 1-877-310-6560.
Washington: WA Office of the Insurance Commissioner at 1-800-562-6900.
Wisconsin: WI Office of the Commissioner of Insurance at 1-800-236-8517.
Wyoming: WY Insurance Department at 1-800-438-5768.

You may also contact the Federal No Surprises Help Desk at 1-800-985-3059 or visit https://www.cms.gov/nosurprises.

State Specific Balance Billing Protections:

California: Strong state protections under Assembly Bill 72 (AB 72) and the Knox-Keene Act ban balance billing for emergency care and non-emergency services provided by out-of-network clinicians at in-network facilities.
Colorado: Colorado's Out-of-Network Health Care Services Act strictly prohibits balance billing for emergency care and out-of-network services rendered at in-network facilities for state-regulated plans.
Connecticut: CT law protects insured patients from balance billing for emergency services and out-of-network surprise bills at in-network facilities. Cost-sharing is capped at in-network rates.
Florida: Florida law protects consumers in PPO and HMO state-regulated plans from balance billing for emergency care and non-emergency care at in-network facilities.
Illinois: Illinois law prohibits balance billing for emergency services and out-of-network facility care, enforcing in-network cost-sharing limits.
Indiana: Indiana law limits surprise billing at in-network facilities and incorporates federal No Surprises Act standards.
Maine: ME law protects consumers enrolled in state-regulated plans from balance billing for emergency services and surprise out-of-network bills at in-network facilities.
Massachusetts: MA law restricts balance billing by certain out-of-network providers, requires advance cost-estimate disclosures, and mandates in-network cost-sharing caps for emergency care.
Michigan: Michigan’s Public Act 234 protects patients from surprise out-of-network bills for emergency care and services provided by non-participating providers at participating facilities.
Nevada: NV law (AB 469) prohibits out-of-network emergency service providers from balance billing covered individuals. Cost-sharing is limited to the in-network amount.
New Hampshire: NH law prohibits balance billing for emergency services and out-of-network ancillary services provided at in-network facilities.
New Jersey: NJ’s Out-of-Network Consumer Protection Act prohibits out-of-network balance billing for emergency or inadvertent out-of-network services. Patients are only responsible for in-network cost-sharing amounts.
New York: NY has robust surprise billing protections (Emergency Medical Services and Surprise Bills Law). Patients are held harmless for emergency care and out-of-network surprise bills at in-network facilities or when referred by an in-network doctor without written consent.
Ohio: OH law (HB 388) prohibits balance billing for emergency services and unanticipated out-of-network care provided at in-network facilities.
Rhode Island: RI law restricts balance billing for emergency services and limits out-of-network charges when receiving care at in-network facilities.
Tennessee: Prohibits balance billing for emergency services and relies on federal standards alongside state administrative rules for out-of-network care.
Texas: Texas Senate Bill 1264 provides strong state protection against balance billing for emergency care and facility-based care in state-regulated plans (TRS, ERS, and state HMOs/PPOs).
Utah: UT state law provides targeted balance billing protections for emergency care. Federal No Surprises Act rules fill in additional protections for non-emergency out-of-network care.
Virginia: Virginia’s Balance Billing Protection Act restricts balance billing for emergency services and surgical/ancillary care at in-network facilities for fully insured plans.
Washington: WA’s Balance Billing Protection Act (BBPA) bans balance billing for emergency services, air ambulance services, and non-emergency surgical/ancillary care at in-network facilities.