Rights and Protections Against Surprise Medical Bills for Emergency Services and Certain Services from Out-of-Network Providers at an In-Network Hospital or Ambulatory Surgical Center
Plan participants are protected from surprise billing, also called balance billing, for emergency care and claims from out-of-network providers that rendered certain services at an in-network hospital or in-network ambulatory surgical center.
The most a provider or facility may bill a participant is the plan’s in-network cost-sharing amount (such as copayments and coinsurance). The provider cannot balance bill for emergency services. This includes services after a patient has been stabilized, unless the patient provides written consent and gives up protections from being balance billed for post-stabilization services.
Certain Services from out-of-network providers at an in-network hospital or ambulatory surgical center
Out-of-network providers at an in-network hospital or in-network surgery center that provide emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeons, hospitalists, or intensivists services, are not permitted to balance bill. They are not permitted to ask a patient to consent to give up protections against balance billing.
Out-of-network providers of other services at in-network facilities may only balance bill a participant if the participant gives written consent and gives up the protections from balance billing.
For information and complaints related to balance billing, contact the U.S. Department of Health & Human Services at 1-800-985-3059 or visit https://www.cms.gov/nosurprises/consumers for more information about the No Surprises Act, payment disputes and patient rights under federal law.
Visit https://www.cms.gov/nosurprises/consumers for more information about your rights under federal law.
More about the No Suprises Act
No Surprises Act introduces a new term called the Qualifying Payment Amount, or QPA, and defines it as the plan’s median contracted rate — the middle amount in an ascending or descending list of contracted rates. The most a provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). The law requires providers to accept the QPA as payment in full for out-of-network emergency services. In addition, certain services provided by out-of-network providers at in-network facilities are also subject to these protections unless the patient provides consent to be billed.