![]() ![]() Your health plan will pay any additional costs to out-of-network providers and facilities directly. 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).When Balance Billing Isn’t Allowed, You Also Have These Protections: You can choose a provider or facility in your plan’s network. You also aren’t required to get out-of-network care. You’re never required to give up your protections from balance billing. You may need to sign a form (available on the Department of Financial Services’ website) for the full balance billing protection to apply. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. If your insurance ID card says “fully insured coverage,” surprise bills include when your in-network doctor refers you to an out-of-network provider without your consent (including lab and pathology services). Services referred by your in-network doctor Surprise bills are when you’re at an in-network hospital or ambulatory surgical facility and a participating doctor was not available, a non-participating doctor provided services without your knowledge, or unforeseen medical services were provided. If your insurance ID card says “fully insured coverage,” you can’t give up your protections for these other services if they are a surprise bill. If you get other types of 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. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, and intensivist services. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. Certain services at an in-network hospital or ambulatory surgical center If your insurance ID card says “fully insured coverage,” you can’t give written consent and give up your protections not to be balance billed for post-stabilization services. This includes services you may get after you’re in a stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services. You can’t be balance billed for these emergency services. If you have an emergency medical condition and get emergency services from an out-of-network provider or hospital, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You’re Protected from Balance Billing for: Emergency Services Surprise medical bills could cost thousands of dollars depending on the procedure or service. 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 billing” is an unexpected balance bill. 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. 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. “Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. 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. When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. What is “Balance Billing” (Sometimes Called “Surprise Billing”)? ![]() In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance, and / or deductible. 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. Your Rights & Protections Against Surprise Medical Bills
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