If you receive emergency treatment, or if you are treated by an out-of-network provider while at an in-network hospital or ambulatory surgical center, federal law offers protections against unexpected or “balance” billing.
What Does “Balance Billing” (or “Surprise Billing”) Mean?
When you visit a doctor or health care provider, you are typically responsible for certain out-of-pocket expenses, such as a copay, coinsurance, or deductible. However, if you receive care from a provider or facility that is not part of your health plan’s network, you may face additional charges or even be billed for the full cost of services.
An “out-of-network” provider or facility is one that does not have a contract with your insurance plan. In some cases, these providers may charge you the difference between what your insurer pays and the total amount billed. This practice is known as “balance billing.” These charges are often higher than in-network costs and may not count toward your annual out-of-pocket maximum.
“Surprise billing” refers to an unexpected balance bill. This can happen when you do not have control over who provides your care—for example, during an emergency, or when you receive treatment at an in-network facility but are unknowingly treated by an out-of-network provider.
Situations Where You Are Protected from Balance Billing
Emergency Care
If you experience a medical emergency and receive services from an out-of-network provider or facility, you are only responsible for your plan’s in-network cost-sharing amounts (such as copays or coinsurance). You cannot be balance billed for these emergency services. This protection also extends to certain follow-up care after you are stabilized, unless you knowingly agree in writing to waive these protections.
Certain Services at In-Network Facilities
Even when you go to an in-network hospital or ambulatory surgical center, some of the providers involved in your care may not be in your network. In these cases, those providers are limited to charging you no more than your plan’s in-network cost-sharing amounts.
This protection applies to a range of services, including:
- Emergency medicine
- Anesthesia
- Pathology
- Radiology
- Laboratory services
- Neonatology
- Assistant surgery
- Hospitalist services
- Intensive care services
These providers are not allowed to balance bill you and cannot require you to give up your protections.
For other types of services at in-network facilities, out-of-network providers generally cannot balance bill you unless you provide written consent agreeing to those charges.
Important Notice
This information is intended to explain your rights under existing law. It does not carry the force of law and is not binding unless it is specifically incorporated into a contract. Its purpose is to help clarify current legal protections for the public.