Understanding your rights and protections against surprise medical bills.
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.
Remember
If you are ever balance billed in an unexpected situation, please call us immediately:
855-447-2900
You have coverage after normal business hours for non-emergency care.
If you believe you’ve been wrongly billed, you may contact the No Surprises Help Desk (NSHD)or call 1-800-985-3059 for more information on your protections under federal law.
What is “balance billing” (sometimes 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 have other costs or have to pay the entire bill if you see a provider or visit a healthcare facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for 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 innetwork facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for these scenarios:
1.
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.
For Montana Members
In Montana for air ambulance services provided by a non-Montana hospital controlled out of network air ambulance service for an emergency medical condition the insurer or health plan shall assume the covered person’s responsibility, if any, for amounts charged in excess of allowed amounts under the plan.
The covered person is still responsible for applicable copayments, coinsurance and deductibles as if the air ambulance services were in-network. An insurer or health plan shall pay or deny the claim and notify a covered person of any deductible, coinsurance, or copayment that is the covered person’s 810 HIALEAH | HELENA, MT 59601 | 855-447-2900 | mhc.coop responsibility to pay within 30 days of receiving an air ambulance claim as described above. Mont. Code Ann. § 33-2-2301 et seq.
2.
Certain services at an in-network hospital or ambulatory surgical center
Certain providers may be out-of-network when you get services from an in-network hospital or ambulatory surgical center.
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.
Remember
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.
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.
Remember
If you are ever balance billed in an unexpected situation, please call us immediately:
855-447-2900
You have coverage after normal business hours for non-emergency care.
If you believe you’ve been wrongly billed, you may contact the No Surprises Help Desk (NSHD)or call 1-800-985-3059 for more information on your protections under federal law.