Your Rights and Protections Against Surprise Medical Bills

​When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

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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, and/or a deductible. You also may have other costs or have to pay the entire bill if you receive care from a provider that is “out-of-network” for your health plan’s network.

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“Out-of-network” means the provider has not 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 agreed to pay and the full amount charged to the plan for a service. This is called “balance billing.” This amount may be more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

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“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 that you do not or cannot choose.

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You are 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 the provider or facility typically may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get at the facility caring for you after you’re in stable condition.

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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 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 can’t balance bill you and may not ask you to give up your protections not to be balance billed. 

If you get certain 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.

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Effect of Specific State Rules

Some states have their own laws relating to balance or surprise billing for out-of-network laboratory or pathology services that may be different from those described here.

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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 or facility in your plan’s network.  

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When balance billing isn’t allowed, you also have these protections: 

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• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles) that you would pay if Patients Choice Laboratories was in-network. Your health plan will pay Patients Choice Laboratories directly.

• Your health plan generally must:

  • Cover emergency services without requiring you to get 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.

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If you think you’ve been wrongly billed: you may file a complaint with the federal government at https://www.cms.gov/nosurprises/consumers or by calling 1-800-985-3059; and/or file a complaint with your state balance billing regulator.

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Visit https://www.cms.gov/nosurprises for more information about your rights under federal law or visit your home state regulator’s website (included in state links above) for more information about your state balance billing rights.