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 collect from you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balanced billed for the difference between 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 certain services other than emergency 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 hospital-based providers: 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 (such as surgeons and other non-hospital-based providers) can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protection 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.
You are only responsible for paying your cost-share responsibility (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 (prior authorization) for services in advance.
- 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 in-network 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.
You have the right to receive a "Good Faith Estimate" explaining how much your non-emergency medical care may cost.
Under the law, health care providers need to give patients who do not have insurance, or who are not using insurance, a cost estimate of the bill for non-emergency medical items and services.
- You have the right to receive a "Good Faith Estimate" for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, drugs, equipment, and hospital fees.
- Your health care provider must give you a "Good Faith Estimate" in writing for scheduled services within three days of a request, three days of scheduling the procedures or one day before the procedure if scheduled less than three. You can ask your health care provider for a "Good Faith Estimate" before you schedule an item or service.
- If you receive a bill that is at least $400 more than your "Good Faith Estimate," you can dispute the bill.