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 https://law.justia.com/codes/new-mexico/2020/chapter-59a/article-16/section-59a-16-21-3/ https://casetext.com/statute/new-mexico-statutes-1978/chapter-59a-insurance-code/article-57a-surprise-billing-protection-act/section-59a-57a-13-repealed-effective-112023providers-reimbursement-for-a-surprise-bill

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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Your Rights and Protections Against Surprise Medical Bills

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

You are protected from balance billing for:

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

State Laws

Arizona

California

Colorado

Connecticut

Delaware

Florida

Georgia

Illinois

Indiana

Iowa

Maryland

Maine

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Nebraska

New Hampshire

New Jersey

New Mexico

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Rhode Island

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