Your Rights and Protections Against Surprise Medical Bills

What is surprise billing?

“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.

What is balance billing?

When you see a doctor or other health care provider, your plan may require you to pay 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.

Under the No Surprises Act, you are protected from balance billing for:

Out-of-network Emergency Services and items, out-of-network services provided at in-network facilities, and out-of-network air ambulance providers.

These protections ban surprise billing in private insurance for most emergency care and many instances of non-emergency care. If you have an emergency medical condition and receive any of the above services from an out-of-network provider or facility, the most the provider or facility may bill you is the plan’s in-network cost-sharing amount (copayments and coinsurance). This includes services you may receive after you’re in stable condition, unless you give written consent and give up your protections not to be balance billed for post-stabilization.

“Once Critique, through MBA, was engaged in our medical management efforts, we found that there was a substantial difference in the year-end results due to lower total claims. This difference was result of fewer hospitalizations & shorter stays as well as improved medical risk in on-going illnesses. These factors created very comfortable renewals for our clients.” 

—William R. Greer, CIC, President, Greer & Assoc.

If you believe you’ve been wrongly billed, contact:

U.S. Department of Labor
Employee Benefits Security Administration (EBSA)
Suite 600
200 Constitution Ave. NW
Washington, DC 20210

866-4-USA-DOL (866-487-2365)

Visit www.dol.gov for more information about your rights under federal law.