Skip to main content

Patient Protections Against Surprise Billing

When you receive emergency care or are treated by an out-of-network provider at an in-network facility, you are protected from surprise billing, also known as balance billing.

What Is Balance Billing?

When you receive care, you may be responsible for certain out-of-pocket costs such as copayments, coinsurance or deductibles. If you receive care from a provider or facility that is out-of-network, they may charge the difference between what your insurance pays and the total cost of the service. This is called balance billing and can result in higher, unexpected charges.

Surprise billing occurs when this happens unexpectedly—such as during an emergency or when you are treated by an out-of-network provider at an in-network facility.

When You Are Protected

You are protected from balance billing in the following situations:

Emergency Services

If you receive emergency care from an out-of-network provider or facility:

  • You can only be charged your plan’s in-network cost-sharing amount
  • You cannot be balance billed for emergency services
  • This includes care received after your condition is stabilized, unless you provide written consent
Services at In-Network Facilities

If you receive care at an in-network hospital or ambulatory surgical center, some providers involved in your care may be out-of-network.

In these cases:

  • You can only be charged your in-network cost-sharing amount

  • You cannot be balance billed for services such as:

    • Emergency medicine
    • Anesthesia
    • Pathology
    • Radiology
    • Laboratory services
    • Neonatology
    • Assistant surgeon services
    • Hospitalist or intensivist care
Out-of-network providers cannot ask you to waive these protections unless you give written consent.

Your Rights

You are never required to give up your protections against balance billing. You also have the right to choose in-network providers whenever possible.

When balance billing is not allowed:

  • You are only responsible for your in-network cost-sharing amounts
  • Your health plan pays out-of-network providers directly

Your health plan is also required to:

  • Cover emergency services without prior authorization
  • Cover emergency services provided by out-of-network providers
  • Base your cost-sharing on in-network rates
  • Count payments toward your deductible and out-of-pocket limits

If You Believe You’ve Been Wrongly Billed

If you think you have been incorrectly charged, you can file a complaint:

For more information, visit:
https://www.cms.gov/nosurprises