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.
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 may have other 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” describes providers and facilities that haven’t signed a contract with your health
plan. Out-of-network providers may be permitted to bill you for the difference between what your
plan agreed to pay 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 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.
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 may bill you is your plan’s in- network
cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed forthese
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 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 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.
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.
When balance billing isn’t allowed, you also have the following protections:
• You are 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 out-of-network providers and facilities directly.
• Your health plan generally must:
o Cover emergency services without requiring you to get approval for services in advance (prior
authorization).
o Cover emergency services by out-of-network providers.
o 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.
o Count any amount you pay for emergency services or out-of-network services toward your deductible
and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact CMS.gov/nosurprises or call
1-800-985-3059. TTY users can use the same phone number. Language lines are available.
Visit CMS.gov/nosurprises for more information about your rights under federal law.
Visit pahealthaccess.org/gethelp/ or call 1-877-888-4877 for more information about your
ghts under Pennsylvania state law.