Your Rights and Protections Against Surprise Medical Bills
Effective: January 1, 2022
When you get emergency care or treated by an out-of-network (OON) provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
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, 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 is not in your health plan’s network.
Out-of-network (OON) describes providers and facilities that have no signed a contract with your health plan. OON 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. For example, 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 OON provider or facility, the most the provider or facility may bill you is for your plan’s in-network cost-sharing amount, such as copayments or coinsurance. You cannot be balance billed for these emergency services. This includes services you may get after you are in stable condition, unless you give written consent and give up your protections not to be balance billed for these post-stabilization services.
Cost Services at an In-Network Hospital or Ambulatory Surgical Center
When you receive services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these instances, the most those providers may bill you is for 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 cannot 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, OON providers cannot balance bill you, unless you give written consent and give up your protections.
You are never required to give up your protections from balance billing. You also are not required to receive care out-of-network. You can choose a provider or facility in your plan’s network.
When Balance Billing Is Not Allowed, You Also Have the Following Protections:
You are only responsible for paying your share of the cost, such as copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network. Your health plan will pay OON providers and facilities directly.
Generally, your health plan must:
- Cover emergency services without requiring you to get approval for services in advance (prior authorization)
- Cover emergency services by OON 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 may pay for emergency services or OON services toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact the Centers for Medicare & Medicaid Services, Department of Health and Human Services at (800) 985-3059.
For services rendered in New Jersey, you also may contact the New Jersey Department of Banking and Insurance at (609) 292-7272 or file an online complaint at: https://www.state.nj.us/dobi/consumer.htm.
For more information about your rights under federal law, visit: https://www.cms.gov/nosurprises/consumers.
For more information about your rights under New Jersey law, visit: https://www.state.nj.us/dobi/index.html.
