• Kentucky

    You may have heard stories from friends or in the news about balance bills or surprise bills from health care providers. Starting in 2022, a new law will protect you from many types of surprise bills. Here are the basics about the new protections and some examples of how they can protect consumers.

    What is balance billing?

    Balance billing happens when a health care provider (a doctor, for example) bills a patient after the patient’s health insurance company has paid its share of the bill. The balance bill is for the difference between the provider’s charge and the price the insurance company set, after the patient has paid any copays, coinsurance, or deductibles.

     Balance billing can happen when a patient receives covered health care services from an out-of-network provider or an out-of-network facility (a hospital, for example).

    In-network providers agree with an insurance company to accept the insurance payment in full, and don’t balance bill. Out-of-network providers don’t have this same agreement with insurers.

    Some health plans, such as Preferred Provider Organization (PPO) or Point of Service (POS) plans, include some coverage for out-of-network care, but the provider may still balance bill the patient if state or federal protections don’t apply. Other plans don’t include coverage for out-of-network services and the patient is responsible for all of the costs of out-of-network care. Medicare and Medicaid have their own protections against balance billing.

    What is surprise billing?

    Surprise billing happens when a patient receives an unexpected balance bill after they receive care from an out-of-network provider or at an out-of-network facility, such as a hospital. It can happen for both emergency and non-emergency care. Typically, patients don’t know the provider or facility is out-of-network until they receive the bill.

    Some states have laws or regulations that protect patients against surprise billing. However, state laws generally don’t apply to self-insured health plans, and most people who get coverage through an employer are in self-insured health plans. Now, a new federal law protects  consumers in self-insured health plans as well as consumers in states that don’t have their own protections.

    What protections are in place?

    A new federal law, the No Surprises Act, protects you from:

    • Surprise bills for covered emergency out-of-network services, including air ambulance services (but not ground ambulance services), and
    • Surprise bills for covered non-emergency services at an in-network facility.

    The law applies to health insurance plans starting in 2022. It applies to the self-insured health plans that employers offer as well as plans from health insurance companies.

    • A facility (such as a hospital or freestanding emergency room (ER)) or a provider (such as a doctor) may not bill you more than your in-network coinsurance, copays, or deductibles for emergency services, even if the facility or provider is out-of-network.
    • If your health plan requires you to pay copays, coinsurance, and/or deductibles for in-network care, you’re responsible for those.
    • The new law also protects you when you receive non-emergency services from out-of-network providers (such as an anesthesiologist) at in-network facilities. An out-of-network provider may not bill you more than your in-network copays, coinsurance, or deductibles for covered services performed at an in-network facility.
      • You can never be asked to waive your protections and agree to pay more for out-of-network care at an in-network facility for care related to emergency medicine, anesthesiology, pathology, radiology, or neonatology—or for services provided by assistant surgeons, hospitalists (doctors who focus on care of hospitalized patients), and intensivists (doctors who care for patients needing intensive care), or for diagnostic services including radiology and lab services.
      • You still can agree in advance to be treated by an out-of-network provider in some situations, such as when you choose an out-of-network surgeon knowing the cost will be higher. The provider must give you information in advance about what your share of the costs will be. If you did that, you’d be expected to pay the balance bill as well as your out-of-network coinsurance, deductibles, and copays.

     

    What else should I know?

    • Your health plan and the facilities and providers that serve you must send you a notice of your rights under the new law.
    • If you’ve received a surprise bill that you think isn’t allowed under the new law, you can file an appeal with your insurance company or ask for an external review of the company’s decision. You also can file a complaint with the [State Insurance Commissioner] or the federal Department of Health and Human Services.
    • An independent dispute resolution (IDR) process, or another process your state sets up, is available to settle bills. Providers and insurance companies can use this process to settle disputes about your bill without putting you in the middle. A similar dispute resolution process is available for individuals who are uninsured, in certain circumstances, such as when the actual charges are much higher than the estimated charges.
    • Other protections in the new law require insurance companies to keep their provider directories updated. They also must limit your copays, coinsurance, or deductibles to in-network amounts if you rely on inaccurate information in a provider directory.

     

    For more information regarding the Federal No Surprises Act and your rights, please visit https://www.cms.gov/nosurprises/consumers/complaints-about-medical-billing or call the Federal No Surprises Help Desk at 1-800-985-3059.

     

    Examples of Surprise Bill Protections

    Q. Deion fell off a ladder, hitting his head and breaking his arm. He was taken to the nearest emergency room. He needed covered imaging and radiology services as well as surgery. Now bills are starting to come in. What is he responsible for paying? How can he get help if he's receiving bills that don't match the explanation of benefits (EOB) from his health insurance plan?

    A. For emergency care he received, Deion is only responsible for paying his in-network deductibles, copays, and coinsurance, even if health care providers who were not in his plan network treated him or he was taken to a facility that was out-of-network. If the bills don’t match his explanation of benefits (EOB), Deion can call his health insurer first. If he isn’t satisfied with the insurer’s response, he can contact KY Department of Insurance.

    If Deion is admitted to the hospital after he receives care in the emergency room, he should know that any out-of-network health care providers at the facility may ask him to consent to continuing care and to agree to pay higher amounts. They can only ask for his consent to receive out-of-network care once he is stabilized, able to understand the information about his care and out-of-pocket costs, and it is safe to travel to an in-network facility using non-emergency transportation. If those conditions are met, Deion can decide if he wants to continue with the out-of-network provider, or travel to a provider who participates in his health plan's network. If he stays with the out-of-network provider and consents to out-of-network billing, he’ll be responsible for any out-of-network deductibles, copays, or coinsurance. He’ll also be responsible for the amount the provider charges that is more than what the insurance company pays (the balance bill).

     

    Q. Bill had chest pains and went to his local hospital's emergency room. The doctors there said he had to be transported to a hospital in a major city for full treatment and he had to go by air ambulance to make it in time. Bill was flown to the larger hospital and is now doing well. Bill's wife, Nancy, has heard scary stories about air ambulance costs and is starting to worry. Are there any protections for someone who is transported by air ambulance in an emergency?

    A. If the air ambulance company has an in-network contract with Bill’s health insurance plan, then Bill will only have to pay the in-network deductibles, coinsurance, or copays. The air ambulance company will accept their contracted amount as payment in full.

    Starting in 2022, the new federal No Surprises Act protects patients even if the air ambulance company doesn’t have an in-network contract with their health insurance plan. Bill will only have to pay the deductibles, copays, or coinsurance that he would have to pay if the air ambulance were in-network. Federal law will help the air ambulance and the health insurance companies determine how to pay the rest of the bill.

    Q. Elena is scheduled for a biopsy, a service that her health plan covers. Her hospital and surgeon are in-network with her health plan, but the hospital uses anesthesiologists and pathologists that are not in-network. Does this mean everything will be covered as in-network, or could Elena have some unexpected charges?

    A. Surgery for a biopsy can involve health care providers that you don’t get to choose, such as an anesthesiologist and a pathologist. Starting in 2022, when Elena chooses an in-network facility and surgeon for her procedure, all of her out-of-pocket costs will be at the in-network rate. That includes the costs for any out-of-network providers she didn’t choose who participate in her care.

     

    Q. Hannah changes jobs and her family is covered under a new employer health plan. Hannah and her husband's doctors are in-network with the new company, but their child’s pediatrician is not. How can they find an in-network pediatrician? Can they rely on the online provider directory for accurate information?

     A. Hannah can review her new health plan’s online provider directory or call the insurance company to get information. An insurance company may have different networks for different health plans. It’s important to look at the directory for your specific health plan.

    Most people rely on their health plan to give them accurate information about in-network health care providers. 

    Starting in 2022, federal law requires health care providers to update their information with insurance companies when there is a change. In turn, insurance companies must verify that the information in their provider directories is complete.

    If Hannah calls the insurance company to ask for a list of in-network pediatricians, the insurance company has one business day to give her a list. If Hannah relies on inaccurate information from the insurance company that a provider is in-network, then Hannah will be responsible only for the in-network deductibles, copays, or coinsurance.

  • Colorado 

    Beginning January 1, 2020, Colorado state law protects you* from “surprise billing,” also known as “balance billing.” These protections apply when:

    • You receive covered emergency services, other than ambulance services, from an out-of-network provider in Colorado, and/or
    • You unintentionally receive covered services from an out-of-network provider at an in-network facility in Colorado.*

    When you CANNOT be balance-billed:

    • Emergency Services
      • If you are receiving emergency services, the most you can be billed is your plan’s in-network cost-sharing amounts, which are copayments, deductibles, and /or coinsurance. You cannot be billed for any other amount. This includes both the facility where you receive emergency services and any providers that see you for emergency services.
      • Please note that not every service provided in an emergency department is an emergency service.
    • Non-Emergency Services at an In-Network Facility by an Out-of-Network Provider
      • The facility or agency must tell you if you are at an out-of-network location or at an in-network location that is using out of network providers. They must also tell you what types of services that you will be using may be provided by an out-of-network provider.
      • You have the right to request that in-network providers perform all covered medical services. However, you may have to receive medical services from an out-of-network provider if an in-network provider is not available. In this case, the most you can be billed for covered services is your in-network cost-sharing amount which are copayments, deductibles, and/or coinsurance. These providers cannot balance bill you for additional costs.

    Additional Protections

    • Your insurer will pay out-of-network providers and facilities directly.
    • Your insurer must count any amount you pay for emergency services or certain out-of-network services (described above) toward your in-network deductible and out-of-pocket limit.
    • Your provider, facility, hospital, or agency must refund any amount you overpay within 60 days of being notified.
    • No one, including a provider, hospital, or insurer, can ask you to limit or give up these rights.

    If you receive services from an out-of-network provider or facility or agency in any OTHER situation, you may still be balance billed, or you may be responsible for the entire bill. If you intentionally receive non-emergency services from an out-of-network provider or facility, you may also be balance billed. 

    If you think you have received a bill for amounts other than your copayments, deductible, and/or coinsurance, please contact the billing department, or the Colorado Division of Insurance at 303-894-7490 or 1-800-930-3745.

    * This law does NOT apply to ALL Colorado health plans. It only applies if:

    • You have a “CO-DOI” on your health insurance ID card, and
    • You are receiving care and services provided at a regulated facility in the state of Colorado.

    Please contact your health insurance plan at the number on your health insurance ID card or the Colorado Division of Insurance with questions.

  • Florida 

    Florida law prohibits surprise billing in emergency situations. In addition, it protects consumers when they are at in-network hospitals for non-emergency services but are unknowingly treated by out-of-network physicians for covered services. Hospitals must post on their websites the health plans with whom they are in-network, and put consumers on notice that patients may be seen by out-of-network practitioners.

    Florida law does not apply to insurance plans from other states or employer-owned insurance plans. Federal law does provide protection for those. For more information on Florida's consumer balance billing protections, please contact the Agency for Health Care Administration, at 1-888-419-3456 / 800-955-8771 Florida Relay Service (TDD number).

    Additional information for consumers is available on the Florida Health Care Complaint Portal flhealthcomplaint.gov

  • Maryland

    If you are in a Health Maintenance Organization (HMO) governed by Maryland law, you may not be balance billed for services covered by your plan, including ground ambulance service. If you are in a PPO or EPO governed by Maryland law, hospital-based or on-call physicians paid directly by your PPO or EPO (assignment of benefits) may not balance bill you for services covered under you plan and can’t ask you to waive your balance billing protections.

    If you use ground ambulance services operated by a local government provider who accepts an assignment of benefits from a plan governed by Maryland law, the provider may not balance bill you.

     

    You also have these protections:

    • You’re 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.
    • Generally, your health plan must:
      • Cover emergency services without requiring you to get approval for services in advance (prior authorization).
      • Cover emergency services by out-of-network providers.
      • 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.
      • Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit. 

    If you think you have been wrongly billed, you may contact the Health Education and Advocacy Unit (HEAU) of Maryland’s Consumer Protection Division:

    Health Education and Advocacy Unit 
    Office of the Attorney General 
    200 St Paul Place, 16th Floor 
    Baltimore, Maryland 21202 
    Phone: 410-528-1840 or toll-free 1-877-261-8807  
    En español: 410-230-1712 
    Fax: 410-576-6571 
    Email: heau@oag.state.md.us 
    Website: https://www.marylandattorneygeneral.gov/Pages/CPD/HEAU   

     

    If you think your health plan processed your claim incorrectly, you may contact the Maryland Insurance Administration:

    Maryland Insurance Administration 
    Life and Health Complaints Unit 
    200 St Paul Place, Suite 2700 
    Baltimore, Maryland 21202 
    Phone: 410-468-2000 or toll free 1-800-492-6116  
    Fax: 410-468-2260 
    Website: http://www.insurance.maryland.gov 

     

    Visit marylandattorneygeneral.gov or insurance.maryland.gov for more information about your rights under Maryland law.

  • Nevada

    Nevada balance billing FAQ’s:

    What is balance billing?

    Balance, or Surprise Billing, is when a consumer is personally billed the difference between the amount of reimbursement paid by the insurance company to the out-of-network provider and the rate that the provider is charging. For example, you have a procedure that is billed $1,000. Your insurance carrier contracts with in-network provider to reduce this to $500. You are responsible for 20% cost share or $100 and the insurance pays $400 to pay the bill in full. At an out-of-network provider you may be billed the same $1,000 and the insurance may still pay the same $400, but because there is no contracted discount rate, the provider will hold you responsible for the full $600 difference, not just the $100 cost share. 

     

    How can I avoid balance billing?

    The best thing to do is to always double check with your carrier and providers that they are in your network. Unfortunately, in emergency situations, this is not always possible.

     

    Are there any laws against balance billing to protect consumers?

    Yes, Nevada has laws in place that prohibit balance billing to the covered person in certain emergency situations. Additionally, a new federal Surprise Billing law that will go into effect 1/1/2022 will offer additional protections.

     

    My large group insurance plan isn't required to follow all of the same state requirements as the ACA plans. Do I still get the balance billing protections? 

    Before 1/1/2022: Sometimes. Large group plans are regulated by the federal government under the Employee Retirement Income Security Act (“ERISA”). These plans have the option to opt-in to Nevada’s balance billing legislation. You will need to contact your plan administrator to determine if this is the case.

    After 1/1/2022: Yes, the new federal law also applies to all ERISA plans.

     

    What is my payment responsibility if I was admitted for an emergency to a hospital that is not in my network?

    Before 1/1/2022: As long as the hospital is not designated as a critical access hospital and your policy was sold in the state of Nevada, any providers that are not contracted with your network can only hold you responsible for the cost share that you would have paid at an in-network provider.
    After 1/1/2022: The hospital and any providers can only hold you responsible for the cost share you would have paid at an in-network provider.

     

    I was pre-approved for surgery at a hospital that is in my network. I found out after the surgery that the anesthesiologist was not in my network. Am I responsible for these changes? 

    Before 1/1/2022:  Nevada law doesn’t address this situation. You may be responsible for these charges.
    After 1/1/2022: Anesthesiology is considered an ancillary service. You are only responsible for the in-network cost share for any ancillary service unless you are given notice and give consent at least 72 hours prior to the date of the procedure.

     

    There is only a non-participating provider at my participating hospital that provides the procedures that I need. Do I have to pay out-of-network cost share? Will I need pre-approval from my insurance carrier?

    Before 1/1/2022: Both of these questions will depend on your specific policy. Nevada law doesn’t determine this. If it is a covered service or medical necessity, contact your insurer prior to the procedure.
    After 1/1/2022:  This is considered as an ancillary service and must be billed at the in-network cost share. The requirements for pre-approval will depend on your specific policy.

     

    Can I be billed for the out-of-network cost share for a provider at an in-network hospital?

    Before 1/1/2022: Sometimes. This can happen for non-emergency procedures, any services provided at a critical access hospital, or if your plan was not sold in Nevada.
    After 1/1/2022: Sometimes. This can happen for non-emergency and non-ancillary procedures provided by a specialist. You can also be billed for certain pre-planned ancillary procedures provided that the out-of-network provider gave notice and received consent at least 72 hours prior to the date of the procedure. Such notice requires that you be given the option to seek care from an in-network provider.

     

    My spouse had a heart attack and the ground ambulance that picked them up was out of our network. Are we responsible for the additional charges for the ambulance since this was an emergency?

    Before 1/1/2022: Nevada law doesn’t address ground ambulance, so you may be responsible for these charges.
    After 1/1/2022: The federal law doesn’t address ground ambulance, so you may be responsible for these charges.

     

    My insurance covers air ambulance, but the ambulance service used was not a participating provider. What costs am I responsible for

    Before 1/1/2022: Nevada law doesn’t address air ambulance services. You may be responsible for these charges.
    After 1/1/2022: You will be responsible for the in-network cost-sharing which must be applied to the in-network deductible and out of pocket limits just as if the air ambulance was an in-network provider. Similarly, plan year in-network deductible and out of pocket limits must apply. 

     

    I'm undergoing cancer treatment, but the facility is no longer a part of my network. What can I do?

    Before 1/1/2022: You may continue to obtain medical treatment for the medical condition from your provider for up to 120 days after the provider left the network if you are actively undergoing a medically necessary course of treatment, and the provider and you agree that it is best for you to continue your care with them.
    After 1/1/2022: Nevada state law offers somewhat more protections than the new federal law in this case. You may continue to obtain medical treatment for the medical condition from your provider for up to 120 days after the provider left the network if you are actively undergoing a medically necessary course of treatment, and the provider and you agree that it is best for you to continue your care with them.

     

    If you believe you've been wrongly billed, file a complaint with the Nevada Division of Insurance (NDI) at https://doi.nv.gov/Consumers/File-A-Complaint/  or call NDI’s Consumer Help Line at (702) 486-4009 or (775) 687-0700.

     

  • Washington

    Beginning January 1, 2020, Washington state law protects you from surprise billing or balance billing if you receive emergency care or are treated at an in-network hospital or outpatient surgical facility

    Insurers are required to tell you, via their websites or on request, which providers, hospitals and facilities are in their networks. And hospitals, surgical facilities and providers must tell you which provider networks they participate in on their website or on request.

    When you CANNOT be balance billed:

    • Emergency Services
      • The most you can be billed for emergency services is your plan’s in-network cost-sharing amount even if you receive services at an out-of-network hospital in Washington, Oregon or Idaho or from an out-of-network provider that works at the hospital. The provider and facility cannot balance bill you for emergency services.
    • Certain services at an In-Network Hospital or Outpatient Surgical Facility
      • When you receive surgery, anesthesia, pathology, radiology, laboratory, or hospitalist services from an out-of-network provider while you are at an in-network hospital or outpatient surgical facility, the most you can be billed is your in-network cost-sharing amount. These providers cannot balance bill you.

    In situations when balance billing is not allowed, the following protections also apply:

    • Your insurer will pay out-of-network providers and facilities directly. You are only responsible for paying your in-network cost-sharing.
    • Your insurer must:
      • Base your cost-sharing responsibility on what it would pay an in-network provider or facility in your area and show that amount in your explanation of benefits.
      • Count any amount you pay for emergency services or certain out-of-network services (described above) toward your deductible and out-of-pocket limit.
    • Your provider, hospital, or facility must refund any amount you overpay within 30 business days.
    • A provider, hospital, or outpatient surgical facility cannot ask you to limit or give up these rights.

    If you receive services from an out-of-network provider, hospital or facility in any OTHER situation, you may still be balance billed, or you may be responsible for the entire bill.

    This law does not apply to all health plans. If you get your health insurance from your employer, the law might not protect you. Be sure to check your plan documents or contact your insurer for more information.

    If you believe you’ve been wrongly billed, file a complaint with the Washington state Office of the Insurance Commissioner at www.insurance.wa.gov or call 1-800-562-6900.

  • Texas

    How Texas protects consumers from surprise medical bills:

    Patients get surprise medical bills if they get care outside their health plan’s network without realizing it. For example, you will probably pick a surgeon in your plan’s network. But you may not be asked about the anesthesiologist. Texas law protects patients with state-regulated health insurance from surprise medical bills in emergencies and when they didn’t have a choice of doctors.

     

    Who qualifies?

    The law applies to state-regulated insurance plans and people with coverage through the state employee or teacher retirement systems – or about 20% of Texans. Insurance cards for state-regulated plans have either “DOI” (for department of insurance) or “TDI” (Texas Department of Insurance) printed on them. (See examples.)

    It does not apply to Medicare or self-funded plans, including many large employer-sponsored plans.

     

    What bills are covered? 

    The law bans balance bills in emergencies or when the patient didn’t have a choice of doctors for medical services received on or after January 1, 2020.

    If you get a balance bill, visit “How to get help with a surprise medical bill” page to learn about your options.

     

    Can I still see the doctor of my choice?

    The law doesn’t limit your options or change your health plan’s coverage for out-of-network care. If your health plan allows you to pick an out-of-network doctor, you can still do so. The new law applies in emergencies and situations where you didn’t select the doctor (such as the radiologist who reviewed your X-ray).

     

    If you believe you’ve been wrongly billed, file a complaint with the Texas Department of Insurance (TDI) at https://www.tdi.texas.gov/medical-billing/smbm-20.html or call TDI’s Consumer Help Line at 800-252-3439.

     

  • Ohio

    The surprise billing law was created to protect patients from receiving and paying surprise medical bills above the patient's in-network rate from health care providers for emergency care or, in certain circumstances, unanticipated out-of-network care. Cost sharing amounts, which include coinsurance, copayments, and deductibles, are limited to the patient’s in-network amounts.


    What is surprise billing and how does it occur?

    Surprise billing happens when you receive an unexpected bill after unanticipated care from an out-of-network health care provider, which can occur at an in-network health care facility such as a hospital, or at an out-of-network health care facility. It can happen for both emergency and non-emergency care. You may be unaware that the health care provider or health care facility is out-of-network until you receive the bill.


    How am I protected from surprise billing?

    New federal and state laws now protect you from receiving and paying medical bills above your in-network insurance amount for unanticipated out-of-network care. Out-of-network care generally is more expensive. Common scenarios in which you are protected include when receiving emergency care at an out-of-network medical facility and receiving scheduled treatment at an in-network medical facility from an out-of-network health care provider.

    Will I still receive a medical bill?

    Yes, you may still receive a medical bill from your provider. Under the new law, you are still responsible for any cost-sharing amounts, which include coinsurance, copayments, deductibles, and all other amounts for which you are contractually responsible, but the amounts are limited to your in-network rates.

    Am I obligated to pay a surprise medical bill?

    You should not be billed above your in-network amounts for receiving out-of-network treatment due to an unanticipated situation. Health care providers are prohibited from balance billing the difference between your in-network and out-of-network amounts. Price and payment reconciliation is now solely between the patient’s health care provider and health insurer.


    What should I do if I receive a surprise medical bill?

    You should not receive surprise medical bills for unanticipated out-of-network care for services performed on or after January 1, 2022. If you receive a surprise bill that you believe is prohibited by state or federal law, first, try to resolve the dispute yourself with your health insurer and health care provider. If the dispute remains unresolved, contact the Ohio Department of Insurance through https://insurance.ohio.gov, consumer.complaint@insurance.ohio.gov, or 800-686-1526 to file a complaint.

    Additional surprise billing information:

    Please visit https://insurance.ohio.gov/strategic-initiatives/surprise-billing/surprise-billing-toolkit to access important educational information and contact us at 800-686-1526 if you have questions.

  • Tennessee

    As of January 1, 2022, Tennessee consumers no longer have to worry about surprise medical bills thanks to the newly enacted No Surprises Act.

    The No Surprises Act is the result of a yearslong bipartisan effort in Congress to help better protect consumers.

    Under the No Surprises Act, a provider may no longer charge the individual for the difference between their charge and the health insurers’ allowed amount. The new law, which is related to either emergency or non-emergency care, ensures Tennesseans and their loved ones can receive the emergency and elective care they need without fear of receiving a surprise bill.

    Tennesseans are shielded under the No Surprises Act, which includes provisions to:

    • Hold patients harmless from surprise medical bills, including air ambulance providers, beyond the applicable in-network cost sharing amount for surprise bills.
    • Require a provider give a patient notice of their network status and an estimate of charges 72 hours prior to receiving out-of-network services, where the patient also must provide consent to receive out-of-network care.
    • Create a framework to allow health care providers and insurers to resolve payment disputes without causing the patient to pay the difference.
    • Provide additional consumer protections if an insurance company adjusts their network. Under the No Surprises Act, if a consumer receives care from a provider who appears on an outdated list of in-network providers, the consumers have to be billed at in-network cost.
    • Allow uninsured consumers (or those who decide to not use health insurance to cover the cost of a service) to get a good faith estimate of the cost of the care up front, before a visit.

    For a list of Frequently Asked Questions related to the No Surprises Act, visit the Centers for Medicare and Medicaid Services’ (CMS) website.

    For additional information, TDCI’s bulletin to Tennessee health care providers and facilities about the No Surprises Act can be seen here.

    If Tennessee consumers should experience a surprise bill, they should file a complaint with our team. To file a complaint, consumers should visit TDCI’s website or call TDCI’s Consumer Insurance Services team at 1-800-342-4029 or (615) 741-2218.

  • Indiana

    Your Rights and Protections Against Surprise Medical Bills

    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.

    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, like a copayment, coinsurance, and/or a 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’re 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 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.

    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 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 an in-network hospital or ambulatory surgical center, outof-network providers can’t balance bill you, unless You give written consent and give up your protections.

     

    Estimate of Charges:

    An out-of-network provider can’t balance bill you unless, at least 5 business days before the services are scheduled to be performed, they give you a good faith estimate of the expected charges for the scheduled services. Indiana law also requires a health care provider or facility to provide an estimate for non-emergency services within 5 business days of receiving a request for one.

    You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.

     

    When balance billing isn’t allowed, you also have these protections:

    • 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:
      • Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
      • Cover emergency services by out-of-network providers.
      • 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.
      • Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

     

    If you think you’ve been wrongly billed, contact the Indiana Department of Insurance at https://www.in.gov./idoi/consumer-services/ or 1-317-232-8582.

    Visit https://www.cms.gov/nosurprises/consumers for more information about your rights under federal law

     

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