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:
If you have an emergency medical condition and get emergency services from an out-of-network
provider or hospital, 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 a stable condition, unless you give written consent
and give up your protections not to be balanced billed for these post-stabilization services. If your
insurance ID card says “fully insured coverage,” you can’t give written consent and give up your
protections not to be balance billed for 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, and intensivist services. These providers can’t
balance bill you and may not ask you to give up your protections not to be balance billed.
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.
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. If your insurance ID
card says “fully insured coverage,” you can’t give up your protections for these other services if they
are a surprise bill. Surprise bills are when you’re at an in-network hospital or ambulatory surgical
facility and a participating doctor was not available, a non-participating doctor provided services
without your knowledge, or unforeseen medical services were provided.
Services referred by your in-network doctor
If your insurance ID card says “fully insured coverage,” surprise bills include when your in-network
doctor refers you to an out-of-network provider without your consent (including lab and pathology
services). These providers can’t balance bill you and may not ask you to give up your protections not
to be balance billed. You may need to sign a form (available on the Department of Financial Services’
website) for the full balance billing protection to apply.
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
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
deductibles 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 innetwork deductible and out-of-pocketlimit.
If you think you’ve been wrongly billed and your coverage is subject to New York law (“fully insured
coverage”), contact the New York State Department of Financial Services at (800) 342-3736 or
email@example.com. Visit http://www.dfs.ny.gov for information about your rights under
Contact CMS at 1-800-985-3059 for self-funded coverage or coverage bought outside New York. Visit
http://www.cms.gov/nosurprises/consumers for information about your rights under federal law.