When you receive 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. Learn more about the No Surprises Act and its consumer protections.
The law is not referring to plan benefits and related out-of-pocket expenses, which are not considered a surprise.
What is “balance billing” (also 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 even have to pay the entire bill if you see a provider or visit a health care facility that is out-of-network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your insurance plan. Out-of-network providers may be permitted to bill you 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:
If you have an emergency medical condition and receive emergency services from an out-of-network provider or health care facility, the provider or facility may only bill up to what your in-network insurance plan’s cost sharing amounts may be.
Balance billing for these emergency services is not allowed. Once you are stabilized, a provider or facility may balance bill you for additional services but only if you give written notice and consent to be balance billed.
Certain services at an in-network hospital or ambulatory surgical center
Sometimes when you receive services from in-network hospitals or ambulatory surgical centers, certain providers working at these in-network facilities may be out-of-network. In these cases, out-of-network providers may only bill up to your plan’s cost-sharing amount.
Balance billing for these services is not allowed unless you give written notice and consent to be balance billed. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services.
You may choose to receive care from providers or health care facilities within your insurance plan’s network. You are not required to receive care from out-of-network providers or facilities. You are never required to give up your protection against balance billing.
You also have the following protections:
- You are only responsible for paying your share of the costs. These costs include copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network. Your insurance plan will pay out-of-network providers and facilities directly.
- Your insurance provider generally must:
- Cover emergency services without requiring you to get approval for services in advance (prior authorization).
- Cover emergency services by out-of-network providers.
- Provide an explanation of benefits showing what you owe based upon what it would pay for in-network providers or facilities.
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
Good Faith Estimates
Uninsured or self-pay patients are entitled to receive an estimate for the total expected costs of any non-emergency services. This includes related costs like medical tests, prescription drugs, equipment and hospital fees. This is called a Good Faith Estimate. It is a right protected by the No Surprises Act.
Uninsured or self-pay individuals must receive the estimate in writing for scheduled medical services. Be sure to get financial counseling before your medical services.
The Financial Clearance Center team is available to answer your questions. They can guide you and give you information about insurance coverage, costs and payment options. They are available Monday-Friday, 8 a.m.-5 p.m. CT.
To inquire about a Good Faith Estimate at MD Anderson, please send the Financial Clearance Center Team a message in MyChart or call them at 844-331-9998.