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 andmay not ask you to give up your protections not to be balance billed.
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.
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’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
•
Generally, your health plan must:
– Cover emergency services without requiring you to get approval for services in advance (also known as “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 in-network deductible and out-of-pocket limit.
If you think you’ve been wrongly billed , you may contact the US Dept. of Health & Human Services at 1-877-696-6775 or your State Insurance Commissioner.
Thecontentsofthis documentdonothavetheforce andeffect oflaw andarenotmeanttobindthepublicin anyway,unless specificallyincorporatedintoacontract. Thisdocument is intended onlytoprovideclarity to thepublic regardingexisting requirementsunderthelaw.
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