QUESTION

What is a balance bill and how can I avoid it?

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, including air ambulances; or

2) When you receive elective nonemergency care at an in-network facility but receive services during your visit or procedure 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 you 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, ensuring they only have to pay for in-network cost sharing in the two situations described above (notably, the federal law does not apply to ground ambulances). Many states have also enacted their own laws to protect enrollees in certain types of health plans, but the new federal laws will act as the minimum level of protection in all states (meaning states cannot set different rules that provide less protection than the new federal law, but your state may have higher standards – check with your state department of insurance to understand your rights).

While the new federal law protects you from paying more than in-network cost sharing in the abovementioned situations, in rare cases, patients may choose to get non-emergency care out of network. In such a circumstance, subject to requirements and limitations, patients may waive their protections. 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 are given a waiver and do not want to consent to paying out-of-network cost sharing, contact your plan and find out if an in-network provider is available. If you believe a provider is impermissibly asking you to waive your rights or refusing you treatment, 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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