Your Rights and Protections Against Surprise Medical Bills

Balance Billing Protection

When you receive emergency care or are treated by an out-of-network provider at an in-network hospital or surgical center, you cannot be balance billed. You should only pay your plan’s copayments, coinsurance, and/or deductible.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or health care provider, you might have to pay some costs, like a copayment or deductible. If you visit a provider or facility not in your health plan’s network, you may face higher costs or have to pay the full bill.

“Out-of-network” refers to providers and facilities that do not have a contract with your health plan. These providers can charge you the difference between what your plan pays and the full service cost, known as “balance billing.” This amount is usually higher than in-network costs for the same service and may not apply to your plan’s deductible or annual out-of-pocket limit.

“Surprise billing” is when you receive an unexpected bill for medical services. This often happens in emergencies or when you go to an in-network facility but are treated by an out-of-network provider. These surprise bills can cost you a lot, sometimes thousands of dollars, depending on the service.

You’re protected from balance billing for:

Emergency services 

If you have a medical emergency and use out-of-network services, the most they can charge you is your plan’s in-network cost-sharing amount (like copayments or coinsurance). You can’t be billed for more than this for emergency services. This protection also covers services after you are stable, unless you provide written consent to waive your protection against additional billing for these follow-up services.

Certain services at an in-network hospital or ambulatory surgical center 

When you use services from an in-network hospital or surgical center, some providers may be out-of-network. In such cases, they can only bill you the in-network cost-sharing amount. This rule applies to services like emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, and intensivist services. These providers cannot balance bill you and cannot ask you to waive your protections against balance billing.

If you receive services at these in-network facilities, out-of-network providers can’t balance bill you unless you agree in writing and waive your protections.

You don’t have to give up your protection from balance billing or choose out-of-network care. You can select a provider or facility that is in your plan’s network.

State Specific Rules

Hawaii

If you’re going to Hawaii and need lab services, remember that the labs must verify if your out-of-state doctor can order tests in Hawaii, as per Hawaii Administrative Rules 11-110.1. If your visit is approaching, call us at 866-281-6816, or you can fax your lab order to 808-677-3970.

State of Hawaii Insurance Division,
Department of Commerce and Consumer Affairs
335 Merchant Street, Room 213
Honolulu, HI 96813
808-586-2790
ihealth@dcca.hawaii.gov

When balance billing isn’t allowed, you also have these protections:

• You only pay your part of the cost (like copayments, coinsurance, and deductibles for in-network providers). Your health plan covers extra costs for out-of-network providers directly.
• Generally, your health plan must:
  • Cover emergency services without needing prior approval.
  • Cover emergency services by out-of-network providers.
  • Base your cost-sharing on what an in-network provider or facility would charge, and include that amount in your explanation of benefits.
  • Count any payments for emergency or out-of-network services towards your in-network deductible and out-of-pocket limit.

If you think you’ve been wrongly billed, contact 1-800-985-3059. Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.