NSA
Your Rights and Protections Against Surprise Medical Bills
When you receive emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing, also known as balance billing.
What is “balance billing” (sometimes called “surprise billing”)?
Balance billing occurs when you receive care from a provider or visit a healthcare facility that is not in your health plan’s network. Out-of-network providers may bill you for the difference between what your plan agrees to pay and the full amount charged for a service. This amount is often higher than in-network costs and may not count toward your annual out-of-pocket limit. Surprise billing happens when you unexpectedly receive care from an out-of-network provider, such as in an emergency or when you are treated by an out-of-network provider at an in-network facility.
You are protected from balance billing for:
Emergency Services
If you have an emergency medical condition and receive services from an out-of-network provider or facility, the most you can be billed is your plan’s in-network cost-sharing amount (e.g., copayments and coinsurance). You cannot be balance billed for these emergency services, including any services you receive after being stabilized unless you give written consent to give up your protections.
Certain Services at an In-Network Hospital or Ambulatory Surgical Center
When you receive care at an in-network hospital or ambulatory surgical center, some providers there may be out-of-network. In these cases, the most they can bill you is your plan’s in-network cost-sharing amount. This protection applies to services such as emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeons, hospitalists, or intensivists. These providers cannot balance bill you and cannot require you to waive your protections.
You are never required to give up your protections from balance billing and are not obligated to receive out-of-network care. You can always choose a provider or facility within your plan’s network.
Additional Protections Against Balance Billing:
- You are only responsible for paying your share of the cost (like copayments, coinsurance, and deductibles) as 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 prior authorization.
- Cover emergency services provided by out-of-network providers.
- Base your cost-sharing responsibility on what it would pay an in-network provider or facility, and reflect 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 have been wrongly billed, you may contact CMS at 1-800-985-3059.
For more information about your rights under federal law, visit www.cms.gov/nosurprises/consumers.
For information about your rights under Michigan state law, visit Michigan DIFS.