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.
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 have protection from balance billing under both federal and state laws. These protections apply to both emergency services and certain services at an in-network hospital or ambulatory surgical center.
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, 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 stable condition unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
In addition to your federal No Surprise Billing protections, if you received services in:
New York: you are protected from surprise medical bills under New York state law and can request a dispute resolution for balance billing.
Pennsylvania: The Pennsylvania Insurance Department coordinates implementation of federal law for Pennsylvania patients. If you receive a surprise medical bill for services provided in Pennsylvania, contact the PA Insurance Department with questions or to file a balance billing complaint.
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, 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 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.
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.
In addition to your federal No Surprise Billing protections, if you received services in:
New York: you are protected from surprise medical bills under New York state law and can request a dispute resolution for balance billing.
Pennsylvania: The Pennsylvania Insurance Department coordinates implementation of federal law for Pennsylvania patients. If you receive a surprise medical bill for services provided in Pennsylvania, contact the PA Insurance Department with questions or to file a balance billing complaint.
You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible 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:
If you believe you’ve been wrongly billed, contact the federal phone number for information and complaints: (800) 985-3059; or visit www.cms.gov/nosurprises for more information about your rights under federal law.
For medical services provided in:
New York: visit: https://www.dfs.ny.gov/consumers/health_insurance/surprise_medical_bills or https://www.dfs.ny.gov/IDR for more information about your rights under New York law. For additional questions, call (800) 342-3736 or email SurpriseMedicalBills@dfs.ny.gov.
To view a list of insurance coverage and health plans, click here.
To view a list of health providers, click here.
Pennsylvania: visit http://www.insurance.pa.gov/NoSurprises for more information about Pennsylvania enforcement of the federal law. For additional questions, call the PA Insurance Department at: (877) 881-6388 or TTY/TDD at: (717) 783-3898.
Note: The No Surprises Act Rights and Protections Against Surprise Medical Bills does not apply to programs like Medicare, Medicare Advantage, Medicaid, Managed Medicaid, Medigap, Children’s Health Insurance Program (CHIP), Indian Health Services, U.S. Department of Veterans Affairs (VA), and standalone Dental or Vision Plans.
