Your Rights and Protections Against Surprise Medical Bills
When you see a doctor or other healthcare provider at Hamilton Endoscopy & Surgery Center, a doctor’s office, a hospital, or another ambulatory surgery center, 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 healthcare 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.” Also known as “surprise 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.
What is Balance Billing?
Balance 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 certain services at an in-network ambulatory surgical center.
When you get services from an in-network ambulatory surgical center, certain providers may be out-of-network. In these cases, the most that providers may bill you is your plan’s in-network cost-sharing amount. This applies to anesthesia, pathology, laboratory, assistant surgeon, 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, ambulatory surgery center, hospital, or another facility in your plan’s network.
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.
Your health plan generally must:
- 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 pay for out-of-network services toward your deductible and out-of-pocket
If you believe you’ve been wrongly billed, you may contact 1-800-985-3059
Visit https://www.cms.gov/nosurprises for more information about your rights under federal law.
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
Under the law, healthcare providers are required to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
- You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
- Make sure your healthcare provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
- If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute it.
- Make sure to save a copy or picture of your Good Faith