Your Rights and Protections Against Surprise Medical Billing
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. In these cases, you shouldn't be charged more than your plan's copayments, coinsurance, and/or deductible.
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, or deductible. You may have additional 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" means providers and facilities that haven't signed a contract with your health plan to provide services. 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. 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.
"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. Surprise medical bills could cost thousands of dollars depending on the procedure or service.
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 they can bill you is your plan's in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). 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 types of services at these 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 out-of-network care. You can choose a provider or facility in your plan's network.
When balance billing isn't allowed, you also have these protections:
You're 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 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, contact the Indiana Department of Insurance at in.gov/idoi/consumer-services 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.
Patient Estimates for Medical Services
We understand when it comes to making the best decision about your care, the financial impact of your treatment or procedure plays an important role. Although costs for all patients are the same, each person's financial responsibility may vary, depending on their insurance coverage. To help you get an estimate of costs, we've created a tool that lists services by category, including specialty services, imaging, labs, surgery, and therapy. Click on the button below then enter a keyword for your service or browse by CPT code (the code used by providers to categorize services) to see your estimate. If you have any questions, we're here to help. Call (765) 983- 3358.