You can receive a “Good Faith Estimate” explaining how much your health care will cost.
Under the law, healthcare providers must give patients who don’t have or are not using certain types of healthcare coverage an estimate of their bill for healthcare items and services before they are provided.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1- 800-985-3059.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or must pay the entire bill if you see a provider or visit a healthcare facility that isn’t in your health plan’s network.
“Out-of-network” means providers and facilities without a contract with your health plan to provide services. Out-of-network providers may bill you for the difference between what your plan pays and the total 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. It 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. Surprise medical bills could cost thousands of dollars, depending on the procedure or service.
Suppose you have an emergency medical condition and get emergency services from an out-of-network provider or facility. In that case, the most they can bill you is your plan’s in-network cost-sharing amount (copayments, coinsurance, and deductibles). 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.
Specific services at an in-network hospital or ambulatory surgical center
Certain providers may be out-of-network when you get services from an in-network hospital or ambulatory surgical center. In these cases, the providers that can bill you the most are 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 types of 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 out-of-network care. You can choose a provider or facility in your plan’s network.
You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible you would pay if the provider or facility were in-network). Your health plan will directly pay any additional costs to out-of-network providers and facilities.
Generally, your health plan must:
If you’ve been wrongly billed, contact the federal phone number for information and complaints at 1-800-985-3059. Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.
For more information regarding state-specific laws, please refer to your state’s No Surprises Act legislation. If you have additional questions, please reach out to the Compliance Hotline at 1-800-308-0994.
