When you receive emergency care or get treated by a provider that does not have an agreement with the Funds, you are protected from balance billing, also known as surprise billing. In these cases, you should not 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, such as a copayment, coinsurance, and/or a deductible. Sometimes providers will attempt to bill you for a doctor’s or other health care provider’s charges after the Funds makes payment. That is called “balance billing.” The Funds encourages beneficiaries to see providers that have agreed to accept the Funds’ payment levels and will not bill you for the balance. These cooperating providers are only permitted to bill you for copayments, deductibles, and non-covered services.
Providers who have not signed an agreement with the Funds may be referred to as “non-cooperating providers.” If a non-cooperating provider attempts to bill you for the difference between what the Funds paid on a claim and the full amount charged for a service, the Funds’ Hold Harmless Program protects you from paying the balance. Now you also have protections under the No Surprises Act for certain services.
“Surprise billing” is an unexpected balance bill that is sent to you after the Funds’ has paid the claim. Sometimes this happens when you have an emergency or when you schedule a visit at a facility that has an agreement with the Funds but are unexpectedly treated by a non-cooperating provider and are billed for the balance after the Funds’ payment. For example:
If you have an emergency medical condition and get emergency services from a Funds’ non-cooperating provider or facility, the most they can bill you is your Funds’ cost-sharing amount (such as copayments 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.
When you get services from a Funds’ cooperating provider that is a hospital or an ambulatory surgical center, the most those providers may bill you is your copayment, coinsurance, and deductible. 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 not to be balance billed. If you get other services at these cooperating providers, non-cooperating providers cannot balance bill you, unless you give written consent and give up your protections.
Please remember that you are never required to give up your protections from balance billing. You can choose any provider for treatment, but the Funds encourages you to use a Funds’ cooperating provider.
When services you will receive will be provided by a non-cooperating provider, you may be asked to sign a consent form that would allow them to bill you for the balance after the Funds’ payment. You are not required to sign these forms.
When balance billing is not allowed, you also have the following protections:
If you believe you’ve been wrongly billed, you may contact the Funds’ Call Center at 1-800-291-1425. The federal phone number for information and complaints is: 1-800-985-3059.
Visit https://www.cms.gov/nosurprises/consumers for more information about your rights under federal law.