OMB Control Number: 0938-1401
Expiration Date: 05/31/2025
Your Rights and Protections
Against Surprise Medical Bills
When you get 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. In these cases, you shouldn’t be charged
more than your plan’s copayments, coinsurance and/or deductible. 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, like a copayment, coinsurance, or deductible. You may have additional 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” means providers and facilities that haven’t signed a contract with your health plan to provide
services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays
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 plan’s deductible or 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. Surprise medical bills could cost thousands of dollars
depending on the procedure or service.
You’re 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 they can bill you is your plan’s in-network cost-sharing amount (such as copayments,
coinsurance, and deductibles). 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.
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 can 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 types of 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 out-of-network care. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have these protections:
You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and
deductible that you would pay if the provider or facility was in-network). Your health plan will pay any
additional costs to out-of-network providers and facilities directly.
Generally, your health plan must:
Cover emergency services without requiring you to get approval for services in advance
(also known as “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 in-network
deductible and out-of-pocket limit.
Under Section 2799B-6 of the Public Health Service Act and its implementing regulations, health care providers,
health care facilities, and providers of air ambulance services are required to provide a good faith estimate of
expected charges for items and services to individuals who are not enrolled in a group health plan or group or
individual health insurance coverage, or a Federal health care program, or a Federal Employees Health
Benefits (FEHB) program health benefits plan (uninsured individuals) or not seeking to file a claim with their
group health plan, health insurance coverage, or FEHB health benefits plan (self-pay individuals) in writing
(and may also provide it orally, if an uninsured (or self-pay) individual requests a good faith estimate in a method
other than paper or electronically), upon request or at the time of scheduling health care items and services.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment.
You could be charged more if complications or special circumstances occur. If this happens, and your bill is
$400 or more for any provider or facility than your Good Faith Estimate for that provider or facility,
federal law allows you to dispute the bill. The Good Faith Estimate is not a contract and does not require the
uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified
in the Good Faith Estimate.
If you think you’ve been wrongly billed, contact the U.S. Department of Health and Human Services (HHS).
If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days
(about 4 months) of the date on the original bill. The federal phone number for information and complaints
is: 1-800-985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process,
visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800- 985-3059.