Surprise Billing Protections

Your rights & protections against surprise medical bills

For patients with insurance:

When you get emergency care or get treated by an out-of-network provider at an in-network hospital, you are protected from balance billing (sometimes called “surprise billing”).

What is “balance billing” or “surprise billing”?

When you see a physician or other 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. 

“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:

1. 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. 
2. Certain services at an in-network hospital:  When you get services from an in-network hospital, certain providers there may be out-of-network. The most these 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. Providers of these types of services can’t balance bill you and may not ask you to give up your protections not to be balance billed.  Providers of other types of services can balance bill you but only if you give written consent and give up your protections. 

• You’re never required to give up your protections from balance billing. You can always go elsewhere and choose a provider or facility in your plan’s network instead. 
• 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 your health plan 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: Catholic Medical Center’s Patient Financial Services Department at 603.663.6922. 
• Visit cms.gov/nosurprises for more information about your rights under federal law.