Your Rights and Protections Against Surprise Medical Bills

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 surprise 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, or deductible. You may have additional costs—or even be responsible for the full bill—if you see a provider or visit a facility that is out-of-network.

“Out-of-network” refers to providers and facilities that have not signed a contract with your health plan. Out-of-network providers may bill you for the difference between what your plan agrees to pay and the full amount charged for a service. This is called balance billing. This amount is usually higher than in-network costs for the same service and may not count toward your annual out-of-pocket limit.

Surprise billing is an unexpected balance bill. It can happen when you cannot control who is involved in your care—such as during 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 they may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You cannot be balance billed for these services.

This protection also applies to post-stabilization services, unless you give written consent to receive care from an out-of-network provider and agree to give up your balance billing protections.

Certain services at in-network hospitals or ambulatory surgical centers

Some providers at in-network facilities may be out-of-network. In these cases, the most these providers may bill you is your plan’s in-network cost-sharing amount. This applies to services such as emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, and intensivist services.

These providers cannot balance bill you and cannot require you to give up your balance billing protections.

For other services at in-network facilities, out-of-network providers cannot balance bill you unless you give written consent to receive care and agree to give up your protections.

You are never required to give up your balance billing protections, and you are not required to receive care from out-of-network providers. You can always choose a provider or facility in your plan’s network.

Additional protections when balance billing isn’t allowed

• You are only responsible for your in-network cost-sharing amounts, such as copayments, coinsurance, and deductibles. Your health plan will pay out-of-network providers and facilities directly.

• Your health plan generally must:

  • Cover emergency services without requiring prior authorization.

  • Cover emergency services provided by out-of-network providers.

  • Base your cost-sharing on what it would pay an in-network provider or facility and show that amount on your explanation of benefits.

  • Count any amounts you pay for emergency or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact the federal Department of Health and Human Services at 1-800-985-3059 or the North Carolina Department of Insurance at 1-855-408-1212.