No Surprise Act

Your Rights and Protections Against Medical Bills

When you get emergency care or are treated by an out-of-network provider 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/or deductible.

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 copayment, coinsurance or deductible. 

“Out-of-network” means that the provider and facility did not sign a contract with your health plan to provide services.  Out-of-network providers may be allowed to bill you for the difference between what your plan pays 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 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, such as having an emergency, or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.  Surprise medical bills could cost thousands of dollars depending on the procedure or services.

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 provider or facility, the most they can bill you is your plan’s in-network cost-sharing amounts. You cannot be balance billed for these emergency services.  This includes services you may get after you’re in a stable condition. 

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 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 cannot balance bill you and may NOT ask you to give up your protections not to be balance 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 protection 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 (copayments, coinsurance, deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
  • Generally, your health plan must:
    • Cover emergency services without requiring you to get an approval for services in advance (also known as “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 EOB.
    • Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

Typically, OMS practices and their scope of treatment does not fall under the IFR’s definition of emergency health care facilities.  However, if you think you’ve been wrongly billed, you may contact us at our Altoona office. 

You can also visit https://www.cms.gov/nosurprises/consumers or call 800-985-3059 for more information about your rights under federal law.