QUESTION

I recently received a surprise medical bill from a doctor or hospital for services that should have been covered by my insurance. What do I do?

Post enrollment issues | Individual Health Insurance Employer-Sponsored Coverage
ANSWER

“Balance bills,” often referred to as surprise medical bills, can occur in two circumstances that can come as a surprise to patients: 1) when you receive emergency care either at an out-of-network facility or from an out-of-network provider, or 2) when you receive elective nonemergency care at an in-network facility but receive services during their stay from an out-of-network health care provider, such as an anesthesiologist, radiologist, hospitalist, or other physician. Since the insurer does not have a contract with the out-of-network facility or provider, it may cover only a portion – or none – of the bill. In that case, the out-of-network facility or provider may then bill the enrollee for the remaining balance of the bill. These bills can be high and are often unexpected, particularly when you have made every effort to get your care at an in-network facility. A new federal law that takes effect in 2022 protects patients from receiving these surprise balance bills, and many states have enacted their own laws, which may provide additional protection for enrollees in certain types of health plans.

If you have received an unexpected bill from either an emergency care situation (including an air ambulance) or from an out-of-network provider when you sought care at an in-network facility, you should contact your insurer. You should also contact your state department of insurance and ask for assistance. Note that the new federal protections do not apply to charges for ground ambulances.

In certain situations, if you voluntarily chose to get non-emergency care out of network and consented to waive your protections against surprise medical bills, you may receive a bill for out-of-network charges not covered by your health plan. However, patients cannot be asked to waive protections for certain specialties, when care is urgent or unforeseen, and where there is no in-network provider available (see here for more information).

If you believe a doctor or hospital impermissibly sent you a surprise bill, asked you to waive your rights, or refused you treatment, you can request an internal appeal and external review. You can also reach out to your state department of insurance.

To learn more about federal protections against surprise medical bills, visit https://www.cms.gov/nosurprises.

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