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 balance billing or surprise billing.
What Is “Balance Billing” (Sometimes Called “Surprise Billing”)?
"Surprise billing" is an unexpected medical bill which happens when you cannot control who is involved in your care.
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 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" describes providers and facilities that have not signed a contract with your medical insurance 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 cannot control who is involved in your care—such as an emergency or if you schedule an appointment at an in-network facility but are unexpectedly treated by an out-of-network provider.
You Are Protected From Balance Billing For
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 are in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Certain 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 in the center 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.
If you receive 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. 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 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 obtain 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 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:
Visit www.cms.gov/nosurprises for more information about your rights under federal law.
Visit www.ncdoi.gov or for more information about your rights under North Carolina law.
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.
Good Faith Estimate
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
Under the law, health care providers need 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 health care 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 health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises