Your Rights and Protections Against Surprise Medical Billing
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.
What is balance billing (sometimes called surprise billing)?
When you see a doctor or other healthcare provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or 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 such as when you have an emergency or when you schedule a visit to an in-network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
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 balance billed for these post-stabilization services.
Certain services at an in-network hospital or ambulatory surgical center
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 an in-network hospital or ambulatory surgical center, out-of-network providers can't balance bill you, unless you give written consent and give up your protections.
Estimate of charges
You may ask for an estimate of the amount you will be charged for a non-emergency medical service provided by a healthcare facility or practitioner. Indiana law requires an estimate be provided within three business days of request for an estimate for a scheduled, ordered, or referred non-emergency healthcare service. In addition, if you are uninsured or intending to pay for the service out-of-pocket, federal law requires a provider or facility give you an estimate for all scheduled non-emergency healthcare services at least one business day before the services are to be performed.
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 (such as 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 owe the provider for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you've been wrongly billed, you may contact the Indiana Department of Insurance at in.gov/idoi or (317) 232-8582.
Visit cms.gov/nosurprises/consumers for more information about your rights under federal law.
Good Faith Estimate
You have the right to receive a "Good Faith Estimate" explaining how much your medical care will cost.
If you don't have insurance or don't intend to use insurance to pay for scheduled non-emergency healthcare services, federal law requires healthcare providers and facilities provide you with an estimate of the expected charges for medical items and services at least 1 business day before the scheduled services are to be performed.
If you are uninsured or not using insurance to pay for your healthcare services and receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Any patient may request an estimate of the expected charges for non-emergency healthcare services that have been ordered, scheduled, or referred and state law requires healthcare providers and facilities provide you with an estimate of the expected bill for medical items and services within 5 business days of the request.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs such as medical tests, prescription drugs, equipment, and hospital fees.
If you request an estimate and the actual charge for the healthcare services exceeds your Good Faith Estimate by the greater of: (i) $100; or (ii) 5%, we will provide a written explanation as to why the charges exceeded the estimate.
Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit cms.gov/nosurprises/consumers or call (800) 985-3059.