Surprise Billing Protection

Effective January 1, 2022, the No Surprises Act, which Congress passed as part of the Consolidated Appropriations Act of 2021, is designed to protect patients from surprise bills for emergency services at out-of-network facilities or for out-of-network providers at in-network facilities, holding them liable only for in-network cost-sharing amounts. The No Surprises Act also enables uninsured patients to receive a good faith estimate of the cost of care.

Billing Disclosures – Your Rights and Protections Against Surprise Medical Bills

When you receive emergency care or treatment from an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise or balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you visit a healthcare provider, you may owe certain out-of-pocket costs, such as copayments, coinsurance, and/or a deductible. If you see a provider or visit a facility not covered by your health plan, you may face additional costs or have to pay the entire bill.

“Out-of-network” refers to providers and facilities not contracted with your health plan. Out-of-network providers may bill you for the difference between what your plan agreed to pay and the full amount charged for a service, termed “balance billing.” This amount is usually higher than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” occurs when you receive an unexpected balance bill. This can happen in situations beyond your control, such as emergencies 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:

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 amount (such as copayments and coinsurance). 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.

Additionally, Ohio law protects patients with coverage through a Health Maintenance Organization (“HMO”) from balance billing for covered services, including emergency services, when the services are provided by an out-of-network provider.

Certain services at in-network hospitals or ambulatory surgical centers

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 can’t 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 in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

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

Additionally, Ohio law also protects patients with coverage through Preferred Provider Organization (“PPO”) or an Exclusive Provider Organization (“EPO”) from balance billing for covered services provided at hospitals, urgent care centers or ambulatory care centers for (1) emergency services and (2) non-emergency services provided at an in-network facility by an out-of-network provider if the patient did not have the opportunity to choose an in-network provider. This protection only requires patients to pay their in-network cost sharing amounts

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

• You are 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.
• Your health plan 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.
  • 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 deductible and out-of-pocket limit.

If you believe you’ve received an incorrect bill, you may contact:

• The U.S. Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (1-800-633-4227) or visit cms.gov/nosurprises for federal law rights information.

Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining your medical care costs.

Under the law, healthcare providers must provide uninsured or non-insurance-using patients with an estimate of medical items and services costs.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.
• Ensure your healthcare provider provides a written Good Faith Estimate at least one business day before your medical service or item. You can also request a Good Faith Estimate before scheduling.
• If you receive a bill at least $400 more than your Good Faith Estimate, you can dispute it.
• Keep a copy or picture of your Good Faith Estimate for your records.

For questions or more information about your right to a Good Faith Estimate, visit cms.gov/nosurprises or call 1-800-MEDICARE (1-800-633-4227).