Your Rights and Protections Against Surprise Medical Bills

When you obtain 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 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 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:

Emergency services

If you have an emergency medical condition and receive 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 cannot be balance billed for these emergency services. This includes services you may receive 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.

See a summary of related state balance billing laws at: https://www.commonwealthfund.org/publications/maps-and-interactives/2021/feb/state-balance-billing-protections.

Certain services at an in-network hospital or ambulatory surgical center 

When you obtain services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those 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. These providers cannot balance bill you and may not ask you to give up your protections not to be balance billed.

If you obtain other services at these in-network facilities, out-of-network 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. Also, you are not required to obtain care out-of-network. You can choose a provider or facility in your plan’s network.

In certain states, you may also have related state protections:

Visit The Commonwealth Fund website for updated state balance-billing protections at https://www.commonwealthfund.org/publications/maps-and-interactives/2021/feb/state-balance-billing-protections.

Applicable state balance billing laws or requirements for noted states are as follows:  

ARIZONA PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• Above protection applies:
  • To HMO and PPO enrollees
  • For (1) emergency services provided by out-of-network professionals at in-network facilities and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• State provides a dispute resolution process for claims over $1000, which must be initiated by the enrollee
• Protections do not apply to:
  • ground ambulance services
  • services at out-of-network facilities
  • enrollees who consent to non-emergency out-of-network services
  • enrollees of self-funded plans

CALIFORNIA PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • For (1) emergency services by out-of-network professionals and facilities and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• State provides a payment standard
• Protections do not apply to:
  • ground ambulance services
  • enrollees who consent to non-emergency out-of-network services
  • enrollees in self-funded plans

COLORADO PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply
  • To HMO and PPO enrollees
  • For (1) emergency services provided by out-of-network professionals, facilities, and ground ambulance service providers and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care providers
• State provides a payment standard
• Protections do not apply:
  • to enrollees who consent to out-of-network non-emergency services
  • to enrollees of self-funded plans

CONNECTICUT PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • For (1) emergency services and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• State provides a payment standard
• Protections do not apply to:
  • ground ambulance services
  • out-of-network facility charges for emergency services
  • enrollees who consent to non-emergency out-of-network services
  • enrollees of self-funded plans

DELAWARE PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for emergency services provided
  • by out-of-network professionals
  • at out-of-network facilities
  • by certain out-of-network ground ambulance service providers
• State prohibits providers from balance billing enrollees for non-emergency services provided at in-network facilities unless they obtain consent from the enrollee
• Above protections apply to:
  • HMO and PPO enrollees
  • For services provided by all or most classes of health care professionals
• State provides a payment standard for emergency services
• State provides the option of arbitration
• Protections do not apply to:
  • enrollees who consent to non-emergency out-of-network services
  • enrollees in self-funded plans

FLORIDA PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • For (1) emergency services by out-of-network professionals and facilities and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• For PPOs, state payment standard applies to (1) emergency services and (2) non-emergency services provided by out-of-network professionals at in-network facilities
• For HMOs, state payment standard only applies to emergency services but the state also has a claim dispute resolution program in place
• Protections do not apply to:
  • ground ambulance services for PPO enrollees
  • PPO enrollees who consent to non-emergency out-of-network services
  • enrollees of self-funded plans

GEORGIA PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • For (1) emergency services by out-of-network professionals and facilities and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• State provides a payment standard for professionals but not facilities
• State provides a dispute resolution process
• Protections do not apply to:
  • ground ambulance services
  • enrollees who consent to non-emergency out-of-network services
  • enrollees in self-funded plans

ILLINOIS PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • For (1) emergency services provided by out-of-network professionals at in-network facilities, and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by certain specific classes of health care professionals
• State provides a dispute resolution process
• Protections do not apply to:
  • ground ambulance services
  • services received at out-of-network facilities
  • enrollees who consent to non-emergency out-of-network services
  • enrollees of self-funded plans

INDIANA PROTECTIONS AVAILABLE

• For HMOs, with respect to emergency services provided by out-of-network professionals and facilities, state (1) requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing; and (2) prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• For HMOs and PPOs, with respect to non-emergency services provided by out-of-network professionals at in-network facilities, state prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing. This prohibition applies to all providers in the state, and therefore might also protect enrollees of self-funded plans.
• Above protections apply to services provided by all or most classes of health care professionals.
• Protections do not apply to:
  • ground ambulance services
  • enrollees who consent to non-emergency out-of-network services

IOWA PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• Above protection applies:
  • To HMO and PPO enrollees
  • For emergency services provided by out-of-network professionals and facilities
  • Provided by all or most classes of health care professionals
• Protections do not apply to:
  • enrollees of self-funded plans
  • non-emergency services

MAINE PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • To enrollees of self-funded plans that have opted into the protections
  • For (1) emergency services by out-of-network professionals, facilities and ambulance providers; and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of out-of-network health care professionals
• State provides a payment standard
• Protections do not apply to enrollees who consent to out-of-network non-emergency services

MASSACHUSETTS PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• Above protection applies:
  • To HMO and PPO enrollees
  • For (1) emergency services provided by out-of-network professionals at in-network facilities, and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of out-of-network health care professionals
• Protections do not apply to:
  • ground ambulance services
  • services at out-of-network facilities
  • enrollees who consent to out-of-network services
  • enrollees of self-funded plans

MARYLAND PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To (1) emergency services provided by out-of-network professionals, facilities, and ambulance providers; and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all types of out-of-network health care professionals for HMO enrollees
  • Provided by on-call or hospital-based physicians who agree to accept assignment of benefits for PPO enrollees
• State provides a payment standard
• Protections do not apply to enrollees in self-funded plans

MICHIGAN PROTECTIONS AVAILABLE

• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • For (1) emergency services by out-of-network professionals and facilities; and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of out-of-network health care professionals
• State provides a payment standard
• State provides a dispute resolution process
• Protections do not apply to:
  • ground ambulance services
  • enrollees who consent to non-emergency out-of-network services
  • enrollees in self-funded plans

MINNESOTA PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• Above protection applies:
  • To HMO and PPO enrollees
  • For non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of out-of-network health care professionals
• State provides a dispute resolution process
• Protections do not apply to:
  • emergency services
  • enrollees of self-funded plans

MISSISSIPPI PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • For (1) emergency services by out-of-network professionals and facilities, and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• Protections do not apply to:
  • ground ambulance services
  • enrollees of self-funded plans

MISSOURI PROTECTIONS AVAILABLE

• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protection applies to:
  • To HMO, PPO, and EPO enrollees
  • For emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• State provides dispute resolution process
• Protections do not apply to:
  • ground ambulance services
  • services provided at out-of-network facilities
  • non-emergency services
  • enrollees of self-funded plans

NEBRASKA PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network professionals and facilities from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • For emergency services
  • Provided by all or most classes of health care professionals
• Protections do not apply to:
  • ground ambulance services
  • non-emergency services
  • enrollees of self-funded plans
• State provides a payment standard

NEVADA PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply
  • To HMO and PPO enrollees
  • To enrollees of self-funded plans that have opted into the protections
  • For emergency services by out-of-network professionals and facilities
  • Provided by all or most classes of health care providers
• State provides a dispute resolution process
• Protections do not apply to:
  • ground ambulance services
  • non-emergency services

NEW HAMPSHIRE PROTECTIONS AVAILABLE

• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protection applies:
  • To any network-based major medical health insurance product, including HMO, PPO, EPO and POS products
  • For (1) emergency services provided by out-of-network professionals at in-network facilities, and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by certain specific classes of health care professionals
• State provides a dispute resolution process
• Protections do not apply to:
  • ground ambulance services
  • services at out-of-network facilities
  • enrollees of self-funded plans

NEW JERSEY PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO, PPO, EPO and POS enrollees
  • To enrollees of self-funded plans that have opted into the protections
  • For (1) emergency services provided by out-of-network professionals and facilities, and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• State provides a dispute resolution process
• Protections do not apply to:
  • ground ambulance services
  • enrollees who consent to non-emergency out-of-network services

NEW MEXICO PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • For (1) emergency services by out-of-network professionals and facilities and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• State provides a payment standard
• Protections do not apply to:
  • ground ambulance services
  • enrollees who consent to out-of-network non-emergency services
  • enrollees of self-funded plans

NEW YORK PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO, PPO and EPO enrollees.
  • For (1) emergency services provided by out-of-network facilities, professionals, and ground ambulance providers; and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• State provides a dispute resolution process
• Protections do not apply to
  • enrollees who consent to non-emergency out-of-network services†
  • enrollees of self-funded plans

NORTH CAROLINA PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • For emergency services by out-of-network professionals
  • Provided by all or most classes of health care professionals
• Protections do not apply to:
  • ground ambulance services
  • emergency services by out-of-network facilities
  • non-emergency services
  • enrollees of self-funded plans

OHIO PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• Above protection applies:
  • To HMO and PPO enrollees
  • For (1) emergency services provided by out-of-network professionals, facilities, and ground ambulance service providers and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by those classes of health care professionals as defined by regulation
• State provides a payment standard
• State provides a dispute resolution process
• Protections do not apply to:
  • enrollees of self-funded plans
  • enrollees who consent to out-of-network non-emergency services

OREGON PROTECTIONS AVAILABLE

• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protection applies:
  • To HMO and PPO enrollees
  • For (1) emergency services provided by out-of-network professionals at in-network facilities, and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• State provides a payment standard
• Protections do not apply to:
  • ground ambulance services
  • services at out-of-network facilities
  • enrollees who consent to non-emergency out-of-network services
  • enrollees of self-funded plans

PENNSYLVANIA PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• Above protection applies:
  • To HMO and PPO enrollees
  • For emergency services
  • Provided by all or most classes of health care professionals
• Protections do not apply to:
  • ground ambulance services
  • out-of-network facility emergency service charges, for PPO enrollees only
  • non-emergency services
  • enrollees of self-funded plans

RHODE ISLAND PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• Above protection applies:
  • To HMO enrollees
  • For (1) emergency services, and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• Protections do not apply to:
  • PPO enrollees
  • ground ambulance services
  • enrollees of self-funded plans

TEXAS PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO, PPO, and EPO enrollees
  • For (1) emergency services by out-of-network professionals and facilities, and (2) non-emergency services provided by out-of-network professionals at in-network facilities
  • Provided by all or most classes of health care professionals
• State provides dispute resolution process
• Protections do not apply to:
  • ground ambulance services
  • enrollees who consent to out-of-network non-emergency services
  • enrollees of self-funded plans

VERMONT PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• Above protection applies:
  • To HMO and PPO enrollees
  • For emergency services including ground ambulance services
  • Provided by all or most classes of health care professionals
• Protections do not apply to:
  • out-of-network facility charges for emergency services
  • non-emergency services
  • enrollees of self-funded plans

VIRIGINA PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • To enrollees of self-funded plans that have opted into the protections
  • For (1) emergency services by out-of-network professionals and facilities, and (2) non-emergency surgical or ancillary services provided by all or most classes of out-of-network professionals at in-network facilities
• State provides a dispute resolution process
• Protections do not apply to ground ambulance services

WASHINGTON STATE PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• State prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing
• Above protections apply:
  • To HMO and PPO enrollees
  • To enrollees of self-funded plans that have opted into the protections
  • For (1) emergency services provided by all or most classes of health care professionals and out-of-network facilities and (2) non-emergency surgical or ancillary services provided by all or most classes of out-of-network professionals at in-network facilities
• State provides a dispute resolution process
• Protections do not apply to ground ambulance services

WEST VIRGINIA PROTECTIONS AVAILABLE

• State requires insurers to hold enrollees harmless for amounts beyond in-network level of cost sharing
• Above protection applies:
  • To HMO enrollees
  • For emergency services including ground ambulance services
  • Provided by all or most classes of health care professionals
• Protections do not apply to:
  • out-of-network facility charges for emergency services
  • non-emergency services
  • enrollees of self-funded plans

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 it would pay an innetwork 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: 

Visit https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/no-surprises-act for more information about your rights under federal law.

Visit https://www.commonwealthfund.org/publications/maps-and-interactives/2021/feb/state-balance-billing-protections for more information about your rights under your state laws.

(For use for plan years beginning on or after January 1, 2022)

Federal law requires group health plans and health insurance issuers offering group or individual health insurance coverage to make publicly available, post on a public website of the plan or issuer, and include on each explanation of benefits for an item or service with respect to which the requirements under section 9816 of the Internal Revenue Code (the Code), section 716 of the Employee Retirement Income Security Act (ERISA), and section 2799A-1 of the Public Health Service Act (PHS Act) apply, information in plain language on:

(1) the restrictions on balance billing in certain circumstances,

(2) any applicable state law protections against balance billing,

(3) the requirements under Code section 9816, ERISA section 716, and PHS Act section 2799A-1, and

(4) information on contacting appropriate state and federal agencies in the case that an individual believes that a provider or facility has violated the restrictions against balance billing.

Plans and issuers may, but aren’t required to, use this model notice to meet these disclosure requirements. To use this document properly, the plan or issuer should review and complete it in a manner consistent with applicable state and federal law. The Departments of Health and Human Services, Labor, and the Treasury (the Departments) will consider use of this model notice in accordance with these instructions to be good faith compliance with the disclosure requirements of section 9820(c) of the Code, section 720(c) of ERISA, and section 2799A-5(c) of the PHS Act, if all other applicable requirements are met.

If a state develops model language for its disclosure notice that is consistent with section 9820(c) of the Code, section 720(c) of ERISA, and section 2799A-5(c) of the PHS Act, the Departments will consider a plan or issuer that makes good faith use of the state-developed model language to be compliant with the federal requirement to include information about state law protections.

Language access

Use of Plain Language

Plans and issuers are encouraged to use plain language in the disclosure notice and test the notice for clarity and usability when possible.

Plain language, accessibility, and language access resources:

• Plainlanguage.gov/guidelines
• Section508.gov
• LEP.gov

Compliance with Federal Civil Rights Laws

Entities that receive federal financial assistance must comply with federal civil rights laws that prohibit discrimination. These laws include section 1557 of the Affordable Care Act, Title VI of the Civil Rights Act of 1964, and section 504 of the Rehabilitation Act of 1973.  Section 1557 and title VI require covered entities to take reasonable steps to ensure meaningful access to individuals with limited English proficiency, which may include offering language assistance services such as translation of written content into languages other than English.

Section 1557 and section 504 require covered entities to take appropriate steps to ensure effective communication with individuals with disabilities, including provision of appropriate auxiliary aids and services. Auxiliary aids and services may include interpreters, large print materials, accessible information and communication technology, open and closed captioning, and other aids or services for persons who are blind or have low vision, or who are deaf or hard of hearing. Information provided through information and communication technology also must be accessible to individuals with disabilities, unless certain exceptions apply. Plans and issuers are reminded that the disclosure notice must comply with applicable state or federal language-access standards.

NOTE: The information provided in these instructions is intended to be only a general summary of technical legal standards. It is not intended to take the place of the statutes, regulations, or formal policy guidance on which it is based. Refer to the applicable statutes, regulations, and other interpretive materials for complete and current information.

Do not include these instructions with the disclosure notice provided to participants, beneficiaries, or enrollees.

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office of Management and Budget (OMB) control number.  The valid OMB control number for this information collection is 1210-XXXX.  The time required to complete this information collection is estimated to average 3.5 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210.Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or get treated by an out-of-network 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 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:

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.

[Insert plain language summary of any applicable state balance billing laws or requirements OR state-developed model language as appropriate]

Certain services at an in-network hospital or ambulatory surgical center 

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those 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. 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 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 care out-of-network. You can choose a provider or facility in your plan’s network.

[Insert plain language summary of any applicable state balance billing laws or requirements OR state-developed model language regarding applicable state law requirements as appropriate]

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 it would pay an innetwork 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.