Balance Billing Act

Your Rights and Protections Against Surprise Medical Bills

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like 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 health care 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—like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider. Surprise 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 the provider or facility may bill you is your plan’s 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 balanced 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.

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.

If you get other types of services at an in-network hospital or ambulatory surgical center, out-of network providers can’t balance bill you, unless you give written consent and give up your protections.

Tennessee Law

In addition to the protections described above, in Tennessee an out-of-network facility may only balance bill you if it provides you with a written notice explaining that the facility is out-of-network and includes an estimate of the amount that the facility will charge you for services.

You’re 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 isn’t allowed, you also have these protections:

  • You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible 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, visit https://www.cms.gov/nosurprises/consumers for more information about your rights under federal law. The federal phone number for information and complaints is 1-800-985-3059. You may also contact the Tennessee Department of Commerce and Insurance at (615) 741-2241 or https://www.tn.gov/commerce/resourcesservices/file-a-complaint

 

UNDERSTANDING YOUR COSTS IN ADVANCE

Beginning January 1, 2022, if you are uninsured or do not plan to file a claim for an item or service, the provider or facility must provide you with a good faith estimate of the expected charges for non-emergency items or services.

The provider must provide you a list of all items and services associated with your care. In 2022 the estimate isn’t required to include items and services provided to you by another facility, (i.e., hospital, surgery center, anesthesia, etc) but you can also ask those facilities for a separate good faith estimate.

Make sure to keep a copy or picture of your good faith estimate.  If you receive a bill and find that the billed amount is greater than $400 above the good faith estimate, you may be eligible to dispute it.

For questions or more information about your right to receive a good faith estimate visit https://www.cms.gov/nosurprises or call HHS at 1-877-696-6775.