As of November 14, 2022
Section 2799B-3 of the Public Health Service Act (PHS Act) requires healthcare providers and facilities to make publicly available,
(1)the federal restrictions on providers and facilities regarding balance billing in certain circumstances,
(2) any applicable state law protections against balance billing, and
(3) information on contacting appropriate state and federal agencies if an individual believes a provider or facility has violated the restrictions against balance billing.
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.
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 provider or visit a healthcare facility that isn’t in your health plan’s network.
“Out-of-network” means providers and facilities that haven’t signed 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—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. Surprise medical bills could cost thousands of dollars depending on the procedure or service.
You’re protected from balance billing for:
• You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and 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 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 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, contact the federal phone number for information and complaints is: 1-800-985-3059.
Visit the Centers for Medicare & Medicaid Services website for more information under federal law: https://www.cms.gov/nosurprises/consumers