When you get 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.

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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.

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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, including Maryland, 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.

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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.

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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 U.S. Department of Health and Human Services​, the Maryland Insurance Administration, or the Maryland Office of the Attorney General's Health Education and Advocacy Unit​.

• 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.

• You can get more information and make complaints to federal agencies by calling 1-800- 985-3059. The Maryland Insurance Administration can be reached at 1-800-492-6116. The Maryland Office of the Attorney General's Health Education and Advocacy Unit can be reached at 1-877-261-8807.

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