No Surprise Billing

Your rights and protections against surprise medical billing

Effective 10/12/2022

When you received emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you’re protected from balance billing. In these cases, you shouldn't be charged more than your plan's co-payments, co-insurance, and/or deductible.

What is balance billing (sometimes called surprise billing)?

When you see a doctor or other healthcare provider, you might owe certain out-of-pocket costs, such as a co-payment, co-insurance, or deductible. You might 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 might 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’re protected from balance billing for:

Emergency services

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 co-payments, co-insurance, and deductibles). You can't be balance billed for these emergency services. This includes services you might 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 might 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 co-payments, co-insurance, and deductibles that you’d 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.

Under the law, healthcare providers need to give patients who don't have certain types of healthcare coverage or who aren’t using certain types of healthcare coverage an estimate of their bill for healthcare items and services before those items and services are provided.

You have the right to receive a Good Faith Estimate for the total expected cost of any healthcare items or services upon request or when scheduling such items or services. This includes costs like medical tests, prescription drugs, equipment, and hospital fees.

If you schedule a healthcare item or service at least three business days in advance, make sure your healthcare provider or facility gives you a Good Faith Estimate in writing within one business day after scheduling. If you schedule a healthcare item or service at least 10 business days in advance, make sure your healthcare provider or facility gives you a Good Faith Estimate in writing within three business days after scheduling.

You can also ask any healthcare provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the healthcare provider or facility gives you an estimate in writing within three business days after you ask.

If you receive a bill that’s at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.

For questions or more information about your right to a Good Faith Estimate, visit cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call (800) 985-3059.

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 might vary, depending on their insurance coverage.