Consolidated Appropriations Act
Your rights and protections against surprise medical bills
Per federal law, you are protected from balance billing or surprise billing when you receive emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center.
Balance billing is when out-of-network providers (those who haven’t signed a contract with your health plan directly or with a provider network with whom your health plan has a contract to provide covered services to members) bill you for the difference between what your plan agrees to pay and the full billed amount for a service. This balance owed may not count towards your plan out-of-pocket maximum.
Surprise billing is an unexpected balance bill. This can happen when you can’t control who is involved in your care, such as an in emergency or when an out-of-network providers treats you at an in-network facility.
You are protected from balance billing for:
Emergency services: An emergency service provider or facility can only bill you for your 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 receive services from an in-network hospital or ambulatory surgical center, certain providers may be out-of-network. Out-of-network emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services providers at these in-network facilities can only bill you for your in-network cost sharing amount. These providers cannot balance bill you and may not ask you to give up your protections not to be balance billed. For other services provided at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You are 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 is not allowed, you are only responsible for in-network cost sharing. For more information on your covered services and protections, please review your member benefit documents.
Additionally, under Massachusetts law, a provider that is licensed in Massachusetts must also disclose their participation in your health plan and expected charges to you upon scheduling your non-emergency service or procedure. You may also request this information from your provider. If your provider fails to provide you with these required notifications, they are not permitted to bill you more than your applicable cost share and you may not be subject to balance billing. For more information, please visit the mass.gov website.
Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance.
- Cover emergency services with out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) for emergency services or certain non-emergency services received from out-of-network providers at certain in-network facilities 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 plan deductible and out-of-pocket maximum.
For more information about your rights under federal and, if applicable, state law or if you feel that a provider or facility has wrongly billed you, you may contact:
• The Commonwealth of Massachusetts, Division of Insurance at (877) 563-4467, Option 2 or www.mass.gov/doi; or
• The Rhode Island Office of the Health Insurance Commissioner by calling RIREACH toll-free: 1- (855)-747-3224 or at http://www.ohic.ri.gov; or
• The No Surprises Help Desk at 1-800-985-3059 or www.cms.gov/nosurprises