Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

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

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay 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 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.

You are 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 the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

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 may 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 can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other 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 protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

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

  • You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
  • Your health plan generally must
    • Cover emergency services without requiring you to get approval for services in advance (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 deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact 844-MYRIAD9 (844-697-4239). Visit https://www.cms.gov/nosurprises for more information about your rights under federal law.

State Laws

Several states also have laws regarding out-of-network services and balance billing or surprise billing. Where available, the state-specific resources in the table below may be able to provide more information or assistance.

State Resources

Arizona

Applicability

Generally applicable to out-of-network providers at in-network facilities and out-of-network emergency
services.

Summary

  • Insurers may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements.
  • Patient may consent to higher, out-of-network charges for non-emergency services.
Contact for Complaints

Department of Insurance and Financial Institutions, https://difi.az.gov/sout-of-networkbdr

Additional Information

https://difi.az.gov/sout-of-networkbdr

California

ApplicabilityGenerally applicable to out-of-network providers at in-network
facilities and out-of-network emergency services.
Summary

  • Providers prohibited from billing beyond in-network amount of cost-sharing.
  • Insurers may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements.
  • Patient may consent to higher, out-of-network charges for non-emergency services.
Contact for Complaints

Department of Insurance, http://www.insurance.ca.gov/01-consumers/101-help/index.cfm

(800) 927-4357

Additional Information

https://www.insurance.ca.gov/01-consumers/110-health/60-resources/NoSupriseBills.cfm

Colorado

Applicability

Generally applicable to out-of-network providers at in-network facilities, and emergency services from
out-of-network providers and facilities.

Summary

  • Providers prohibited from billing beyond in-network amount of cost-sharing.
  • Insurers may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements.
  • Patient may consent to higher, out-of-network charges for non-emergency services.
Contact for Complaints

https://doi.colorado.gov/for-consumers/file-a-complaint

For questions about whether federal or state law applies:

(303) 894-7490

(800) 930-3745 (outside the Denver Metro area)

Additional Information

https://doi.colorado.gov/insurance-products/health-insurance/health-insurance-initiatives/out-of-network-health-care

Connecticut

Applicability

Generally applicable to out-of-network providers at in-network facilities, as well as emergency
services.

Summary

  • Providers prohibited from billing beyond in-network amount of cost-sharing.
  • Insurers may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements.
  • Patient may consent to higher, out-of-network charges for emergency services.
Contact for Complaints

Office of the Healthcare Advocate, https://portal.ct.gov/OHA/Resources/Release-of-Information/Request-Assistance

(866) 466-4446

Additional Information

https://www.cga.ct.gov/2020/rpt/pdf/2020-R-0204.pdf

Delaware

Applicability

See below.

Summary

  • Insurers may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements
    for emergency services.
  • Providers prohibited from billing beyond in-network amount of cost-sharing.
  • Patient may consent to higher, out-of-network charges for emergency services.
Contact for Complaints

Delaware Department of Insurance, Consumer Services Division, https://insurance.delaware.gov/services/filecomplaint/

(302) 674-7310

Additional Information

https://legis.delaware.gov/SessionLaws/Chapter?id=19067

Florida

Applicability

  • Generally applicable to out-of-network providers at in-network facilities and out-of-network
    emergency providers and facilities.
  • Patient may consent to higher, out-of-network charges.
Summary

  • Providers prohibited from billing beyond in-network amount of cost-sharing.
  • Insurers may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements.
  • PPO enrollees using non-emergency services may consent to higher, out-of-network charges.
Contact for Complaints

Florida Health Care Complaint Portal, https://www.flhealthcomplaint.gov/

Additional Information

http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0600-0699/0627/Sections/0627.64194.html

Georgia

Applicability

Generally applicable to out-of-network providers at in-network facilities and out-of-network emergency
providers and facilities.

Summary

  • Providers prohibited from billing beyond in-network amount of cost-sharing.
  • Insurers may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements.
  • Patient may consent to higher, out-of-network charges for non-emergency services.
Contact for Complaints

Office of Commissioner of Insurance and Safety Fire, Report Complaints & Fraud, https://oci.georgia.gov/insurance-resources/complaints-fraud

(404) 656-2070

Additional Information

https://oci.georgia.gov/document/document/final-rules-and-regulations-surprise-billing/download

https://consumer.georgia.gov/consumer-topics/hospital-billing-practices

Illinois

Applicability

  • Only applicable to facility-based providers, defined as physicians or other providers who
    provide
    radiology, anesthesiology, pathology, neonatology, or emergency department services.
  • Only applicable to out-of-network providers at in-network facilities, whether emergency or
    non-emergency.
Summary

  • Providers prohibited from billing beyond in-network amount of cost-sharing when referred.
  • Insurers may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements.
  • Patient may consent to higher, out-of-network charges for non-emergency services.
Contact for Complaints

Illinois Department of Insurance, How to File a Complaint, https://www2.illinois.gov/sites/Insurance/Consumers/Pages/File-a-complaint.aspx

(312) 814-2420

Additional Information

https://ilga.gov/legislation/ilcs/documents/021500050K356z.3.htm

 

https://www.ilga.gov/legislation/ilcs/fulltext.asp?DocName=021500050K356z.3a

Indiana

ApplicabilitySee below.
Summary

  • Providers prohibited from billing beyond in-network amount of cost-sharing for 1) HMO and PPO
    enrollees when seeing out-of-network provider at in-network facility in non-emergency settings
    and
    2) HMO enrollees for out-of-network providers and out-of-network facilities in emergency
    settings.
  • Insurers may not hold Health Maintenance Organization (HMO) patients responsible for amounts
    beyond
    in-network cost-sharing requirements out-of-network provider and facility emergency services.
  • Patient may consent to higher, out-of-network charges for non-emergency services.
Contact for Complaints

Indiana Attorney General, Consumer Complaint, https://www.in.gov/attorneygeneral/consumer-protection-division/file-a-complaint/consumer-complaint/

(317) 232-6330

Additional Information

http://184.175.130.101/legislative/2020/bills/house/1004#document-5861a895

Iowa

Applicability

Only applicable to out-of-network emergency services.

Summary

  • Insurers may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements.
  • No consent exception.
Contact for Complaints

Iowa Insurance Division, File a Consumer Complaint, https://iid.iowa.gov/insurance-consumer-complaint

(515) 654-6538

Additional Information

https://www.legis.iowa.gov/docs/code/514C.16.pdf

Maryland

Applicability

Generally applicable to out-of-network providers at in-network facilities, out-of-network emergency
services, all out-of-network services for HMO enrollees, and on-call or hospital-based physicians who
accept
PPO referrals.

Summary

  • Providers prohibited from billing beyond in-network amount of cost-sharing.
  • Insurers may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements.
  • No consent exception.
Contact for Complaints

Maryland Attorney General, Consumer Protection Division’s Health Education and Advocacy Unit, https://www.marylandattorneygeneral.gov/Pages/CPD/Tips-Publications/tip41.aspx

(410) 528-1840

Additional Information

https://insurance.maryland.gov/Consumer/Documents/publications/AssignmentofBenefitsFAQ.pdf

Maine

Applicability

Generally applicable to out-of-network providers at in-network facilities and out-of-network emergency
services.

Summary

  • Providers prohibited from billing beyond in-network amount of cost-sharing.
  • Insurers may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements.
  • Patient may consent to higher, out-of-network charges for non-emergency services.
Contact for Complaints

Maine Attorney General, Consumer Complaints or Questions, https://www.maine.gov/ag/consumer/complaints/index.shtml

(207) 626-8849

Additional Information

https://legislature.maine.gov/statutes/22/title22sec1718-D-1.html

Massachusetts

Applicability

Generally applicable to out-of-network providers at in-network facilities and out-of-network emergency
services.

Summary

  • Insurers may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements
    if the statute’s notice requirements have not been met.
  • Providers prohibited from billing beyond in-network amount of cost-sharing if statute’s notice
    requirements have not been met.
  • Patient may consent to higher, out-of-network charges.
Contact for Complaints

Massachusetts Attorney General’s Health Care Division, https://www.mass.gov/how-to/file-a-health-care-complaint

(888) 830-6277

Additional Information

https://malegislature.gov/Bills/191/S2984.pdf

Michigan

Applicability

Generally applicable to out-of-network providers at in-network facilities (contingent on there being no
in-network providers, lack of disclosure, or post-emergency setting) and out-of-network emergency
services.

Summary

  • Providers prohibited from billing beyond in-network amount of cost-sharing.
  • Patient may consent to higher, out-of-network charges for non-emergency services.
Contact for Complaints

Department of Insurance and Financial Services, Filing a Complaint with DIFS, https://www.michigan.gov/difs/0,5269,7-303-12902_12907—,00.html

(877) 999-6442

Additional Information

https://www.michigan.gov/difs/0,5269,7-303-13222_13250-561696–,00.html

Minnesota

Applicability

Only applicable to non-emergency out-of-network services at in-network facilities; statute specifically
includes in-network provider collecting specimen sent to non-participating lab.

Summary

  • Insurers may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements.
  • No consent exception.
Contact for Complaints

Minnesota Attorney General, Medical Billing Pointers, https://www.ag.state.mn.us/consumer/publications/MedicalBillingPointers.asp

(651) 296-3353 (Twin Cities Calling Area)

(800) 657-3787 (Outside Twin Cities)

Additional Information

https://www.revisor.mn.gov/statutes/cite/62Q.556

Mississippi

Applicability

Generally applicable to out-of-network providers at in-network facilities (when referred) and
out-of-network
emergency services.

Summary

  • Providers prohibited from billing beyond in-network amount of cost-sharing when referred.
  • Insurers may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements.
  • No consent exception.
Contact for Complaints

Mississippi Attorney General, Consumer Complaint Form, https://www.ago.state.ms.us/divisions/consumer-protection/consumer-complaint-form/

(601) 359-4230

Mississippi Insurance Department, (800) 562-2957

Additional Information

https://www.mid.ms.gov/healthcare/questionsanswers/TopicTwo.pdf

Missouri

Applicability

Only applicable to out-of-network providers (not at out-of-network facilities) in emergency setting.

Summary

  • Providers prohibited from billing beyond in-network amount of cost-sharing.
  • No consent exception.
Contact for Complaints

Missouri Department of Insurance, Managing Health Care Costs, https://insurance.mo.gov/consumers/health/managingcost.php

(800) 726-7390

Additional Information

https://revisor.mo.gov/main/OneSection.aspx?section=376.690#:~:text=376.690.,external%20arbitration%20process%20%E2%80%94%20rulemaking%20authority

Nebraska

Applicability

Only applicable to providers in emergency setting.

Summary

  • Providers prohibited from billing beyond in-network amount of cost-sharing.
  • Insurers may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements.
  • Patient may consent to higher, out-of-network charges.
Contact for Complaints

Nebraska Attorney General’s Office, File a Complaint, https://www.nebraska.gov/apps-ago-complaints/?preSelect=CP_COMPLAINT

(402) 471-2682

Additional Information

https://doi.nebraska.gov/sites/doi.nebraska.gov/files/doc/ConsumerFactSheetBalanceBillingandOutofNetworkProviders.pdf

New Hampshire

Applicability

Applicable to certain out-of-network providers at in-network facilities (anesthesiology, radiology,
emergency medicine, or pathology services) and out-of-network emergency services at in-network
facilities.

Summary

  • Providers prohibited from billing beyond in-network amount of cost-sharing.
  • No consent exception.
Contact for Complaints

New Hampshire Insurance Department, Consumer Complaints and Other Investigations, https://www.nh.gov/insurance/complaints/index.htm

(800) 852-3416

Additional Information

https://www.nh.gov/insurance/media/bulletins/2019/documents/ins-19-015-ab-hb-1809-nh-balance-billing-and-network-adequacy-laws.pdf

New Jersey

Applicability

  • Generally applicable to out-of-network providers at in-network facilities and out-of-network
    emergency services.
  • Patient may consent to higher, out-of-network charges.
Summary

  • Providers prohibited from billing beyond in-network amount of cost-sharing.
  • Insurers may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements.
Contact for Complaints

Department of Banking & Insurance, How to Request Assistance, https://www.state.nj.us/dobi/consumer.htm

(609) 292-7272

Additional Information

https://www.state.nj.us/dobi/division_consumers/insurance/outofnetwork.html

New Mexico

Applicability

Generally applicable to out-of-network providers at in-network facilities and out-of-network emergency
services.

Summary

  • Providers prohibited from billing beyond in-network amount of cost-sharing.
  • Insurers may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements.
  • Patient may consent to higher, out-of-network charges for non-emergency services.
Contact for Complaints

New Mexico Attorney General, Consumer Complaint Instructions, https://www.nmag.gov/consumer-complaint-instructions.aspx

(844) 255-9210

Additional Information

New York

Applicability

Generally applicable to out-of-network providers at in-network facilities (when referred) and
out-of-network
emergency services.

Summary

  • Providers prohibited from billing beyond in-network amount of cost-sharing when referred.
  • Insurers may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements.
  • Patient may consent to higher, out-of-network charges for non-emergency services.
Contact for Complaints

Department of Financial Services, https://www.dfs.ny.gov/IDR

Additional Information

https://www.dfs.ny.gov/consumers/health_insurance/surprise_medical_bills

Nevada

Applicability

Only applicable to emergency out-of-network providers and facilities.

Summary

  • Providers prohibited from billing beyond in-network amount of cost-sharing.
  • Insurers may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements.
  • No consent exception.
Contact for Complaints

Division of Insurance, https://doi.nv.gov/Consumers/File-A-Complaint/

Additional Information

https://doi.nv.gov/Consumers/Health_and_Accident_Insurance/Balance_Billing_FAQs/

North Carolina

Applicability

Only applicable to out-of-network providers in emergency setting.

Summary

  • Insurers may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements.
  • No consent exception.
Contact for Complaints

Department of Insurance, https://www.ncdoi.gov/assistance-or-file-complaint

(855) 408-1212

Additional Information

https://www.ncleg.gov/EnactedLegislation/Statutes/PDF/BySection/Chapter_58/GS_58-3-250.pdf

Ohio

Applicability

Generally applicable to out-of-network providers at in-network facilities and out-of-network emergency
services.

Summary

  • Insurers may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements.
  • Patient may consent to higher, out-of-network charges for non-emergency services.
Contact for Complaints

Ohio Department of Insurance, Surprise Billing, https://insurance.ohio.gov/wps/portal/gov/odi/consumers/health/surprise-billing

Additional Information

https://insurance.ohio.gov/wps/portal/gov/odi/consumers/health/surprise-billing

Oregon

Applicability

Generally applicable to out-of-network providers at in-network facilities and out-of-network emergency
services.

Summary

  • Providers prohibited from billing beyond in-network amount of cost-sharing.
  • Patient may consent to higher, out-of-network charges for non-emergency services.
Contact for Complaints

Department of Consumer and Business Services, https://dfr.oregon.gov/help/complaints-licenses/Pages/file-complaint.aspx

Additional Information

https://dfr.oregon.gov/news/2018/Pages/20180301-balance-billing.aspx

Pennsylvania

Applicability

Only applicable to out-of-network emergency services.

Summary

  • Managed care plans are required to cover out-of-network emergency services without prior
    authorization.
Contact for Complaints

Pennsylvania Insurance Department, File a Complaint, https://www.insurance.pa.gov/Consumers/insurance-complaint/Pages/default.aspx

Additional Information

Insurance commission page only covers No Surprises Act: https://www.insurance.pa.gov/Coverage/health-insurance/no-surprises-act/Pages/default.aspx

Rhode Island

Applicability

Applicable to out-of-network emergency services and out-of-network providers at in-network
facilities.

Summary

  • Health Maintenance Organizations (HMOs) may not hold patients responsible for amounts beyond
    in-network cost-sharing requirements.
  • No consent exception.
Contact for Complaints

Office of Health Insurance Commissioner, http://www.ohic.ri.gov/ohic-consumers.php

Additional Information

https://law.justia.com/codes/rhode-island/2020/title-27/chapter-27-41/section-27-41-26/

Texas

Applicability

Generally applicable to out-of-network providers at in-network facilities and out-of-network emergency
services and facilities.

Summary

  • Providers prohibited from billing beyond in-network amount of cost-sharing.
  • Health Maintenance Organizations (HMOs) and Exclusive Provider Organizations (EPOs) (but not
    Preferred Provider Organizations (PPOs)) may not hold patients responsible for amounts beyond
    in-network cost-sharing requirements.
  • Patient may consent to higher, out-of-network charges for non-emergency services.
Contact for Complaints

Department of Insurance: https://www.tdi.texas.gov/medical-billing/surprise-balance-billing.html

Additional Information

https://www.tdi.texas.gov/tips/texas-protects-consumers-from-surprise-medical-bills.html

Vermont

Applicability

Only applicable to emergency providers.

Summary

  • Managed care plans may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements.
Contact for Complaints

Department of Financial Regulation, https://dfr.vermont.gov/consumers/file-complaint/insurance/insurance-complaints

Additional Information

https://dfr.vermont.gov/sites/finreg/files/regbul/dfr-regulation-health-h-2009-03-revised-consumer-protection-managed-care.pdf

Virginia

Applicability

Applicable to certain out-of-network providers at in-network facilities (surgical or ancillary services:
surgery, anesthesiology, pathology, radiology, laboratory, or hospitalist services) and out-of-network
emergency providers and facilities.

Summary

  • Providers prohibited from billing beyond in-network amount of cost-sharing.
  • Insurers may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements.
  • No consent exception.
Contact for Complaints

State Corporation Commission, https://scc.virginia.gov/getattachment/c9bb945e-2b7c-448a-a940-9ba939f15b25/BB-Complaint-Form.pdf

Additional Information

https://scc.virginia.gov/pages/Balance-Billing-Protection

Washington

Applicability

Only applies to emergency services and surgical or ancillary services (surgery, anesthesiology,
pathology,
radiology, laboratory, or hospitalist services).

Summary

  • Providers prohibited from billing beyond in-network amount of cost-sharing.
  • Insurers may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements.
  • No consent exception.
Contact for Complaints

Office of the Insurance Commissioner, https://www.insurance.wa.gov/file-complaint-or-check-your-complaint-status

Additional Information

https://www.insurance.wa.gov/what-consumers-need-know-about-surprise-or-balance-billing

West Virginia

Applicability

Only applies to emergency services.

Summary

  • Insurers may not hold patients responsible for amounts beyond in-network cost-sharing
    requirements.
  • No consent exception.
Contact for Complaints

Office of Insurance Commissioner, https://www.wvinsurance.gov/Consumer_Services

Additional Information

https://code.wvlegislature.gov/16-29D-4/

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