Your Rights and Protections Against Surprise Medical Bills

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

When you see a mental health care provider, you may owe certain out-of-pocket costs, like a copayment or coinsurance. You may have additional costs or have to pay the entire bill if you see a provider or visit a facility that isn’t in your health plan’s network.

“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays 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 plan’s deductible or 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 they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). 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 balances billed for these post-stabilization services.

You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider in your plan’s network.

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

• You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible) that you would pay if the provider was in-network. Your health plan will pay any additional costs to out-of-network providers and facilities directly.
• Generally, your health plan must cover emergency services without requiring you to get approval in advance and cover emergency services by out-of-network providers.

If you think you’ve been wrongly billed, contact the Centers for Medicaid and Medicare Services (CMS) at 1-800-985-3059

Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law