Know 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.
Effective January 1, 2022, a new law known as the “No Surprises Act” protects patients from balance billing and surprise billing. This includes the following:
- 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 amounts. 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 balance 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 cannot balance bill you and may not ask you to give up your protections to no be balance billed.
You are NEVER required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can always choose a provider or facility in your plan’s network if you chose other care elsewhere.
The following link leads to the machine readable files that are made available in response to the federal Transparency in Coverage Rule and includes negotiated services rates and out-of-network allowed amounts between health plans and healthcare providers. The machine-readable files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.
- If you believe you have been wrongly billed, you may contact your insurance company to verify if a provider is in network and/or The Kentucky Department of Insurance at 1-800-595-6053 Monday through Friday from 8 a.m. to 5 p.m. or Department of Health and Human Services (HHS) at 1-800-985-3059 or visit https://www.cms.gov/nosurprises/consumers
The rules don’t apply to people with coverage through programs like Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE because these programs have other protections against high medical bills.
Self-Pay or Uninsured Good Faith Estimate Facts
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your healthcare needs for an item or service rendered. The estimate is based on information known at the time the estimate was created.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.
You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. Ask to negotiate the bill or ask if there is financial assistance available. If the uninsured (or self-pay) individual is billed for an amount at least $400 above the estimate, the individual may be eligible to start a Patient Provider Dispute Resolution (PPDR) process by submitting a request to HHS and paying a small administrative fee.
You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute within 120 calendar days (about 4 months) of the date on the original bill.
There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on the Good Faith Estimate. If the agency disagrees with you and agrees with the healthcare provider or facility, you will have to pay the higher amount.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 1-800-985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises/consumers or call 1-800-985-3059.
Keep a copy of this Good Faith Estimate in a safe place or take a picture of it. You may need it if you are billed a higher amount.