Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
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, such as a copayment, coinsurance, and/or a deductible. You may have other 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” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay 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 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.
You are protected from balance billing for:
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.
If you get other services 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’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.
State Law Protections
Please refer to Addendum A for a list of states that Uprise operates in and how those states address surprise billing for their residents.
When balance billing isn’t allowed, you also have the following protections:
- You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
- Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (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 deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact: The No Surprises Helpdesk at 1-800-985-3059.
For more information about your rights under federal law, visit https://www.cms.gov/nosurprises.
Addendum A to Protections Against Surprise Medical Bills
The following states that Uprise operates in address surprise billing for their residents in the following ways:
- An out-of-network provider cannot bill you an amount that exceeds your in-network cost-sharing requirement for (i) emergency services, including post-stabilization care, or (ii) nonemergency services, including diagnostic, imaging lab services, and other outpatient settings, provided by out-of-network providers at in-network facilities.
- If you have signed a consent to receive services and have elected to be responsible for the provider’s billed charges, an out-of-network provider may be allowed to balance bill you. The consent must disclose an estimate of the total amount you may be responsible for and that you can elect to receive services from an in-network provider.
- An out-of-network air ambulance provider cannot bill you an amount that exceeds your in-network cost-sharing requirement for covered services.
- California’s balance billing prohibition above covers enrollees of California state-regulated health plans.
- If you pay an out-of-network provider an amount that exceeds your in-network cost-sharing requirement for emergency services or nonemergency services as set forth in California’s balance billing protection, you may be entitled to a refund of the excess amount that you paid to the provider.
- Colorado law protects patients holding Division of Insurance (DOI) regulated health insurance plans and patients covered by managed care plans from surprise medical bills for health care services provided at an in-network facility by an out-of-network provider.
- Colorado law also protects you from surprise medical bills for emergency services, even if the emergency services are out-of-network or provided by an out-of-network provider. You are only required to pay your in-network rates.
- Colorado law does not protect you from surprise medical bills when you intentionally use an out-of-network provider.
- Indiana law protects you from balance billing for non-emergency services provided by out-of-network providers at in-network facilities. This protection does not apply if you have received advanced notice from an out-of-network provider and consent to the pricing of the healthcare services.
- This protection limits your financial liability to the rate paid to the out-of-network provider by your network plan plus any in-network cost-sharing amounts. This prohibition applies to all patients with coverage through a network plan.
- Indiana law also protects you from balance billing if you have coverage through an HMO for: emergency services received from an out-of-network provider or at an out-of-network facility and any covered services performed by an out-of-network provider when the covered service is not available through in-network providers, provided you have a referral. Indiana law requires you to pay only in-network expenses.
- Iowa law requires health plans to cover charges for healthcare services necessary to evaluate and stabilize an emergency medical condition.
- If you have a PPO Plan, your PPO Plan may require you to pay the difference between an out-of-network physician’s bill for a health care service and the amount your PPO Plan pays (i.e., a balance bill) before any cost sharing amounts are charged and applied. In such case, your PPO Plan must pay at least what they pay in-network providers to reduce balance billing charged to you. Further, we will provide you a statement that:
- we are an out-of-network nonpreferred provider;
- we may charge you for noncovered services;
- we may charge you a balance bill for covered services;
- includes an estimate of the cost of services we expect to provide you; and
- explains terms of payment, including whether interest will apply.
- If you have a Maryland health maintenance organization policy (“HMO Plan”), your HMO Plan may limit referrals to a provider panel and without providing direct access (i.e., without a referral from your primary care physician) to specialists such as those at WOSM. You have the right to choose care outside of this provider panel. If you choose such care, including through WOSM, outside of a provider panel, you may receive balance billing for the service unless your HMO Plan does not have a specialist with the training or expertise to treat your condition or disease without unreasonable delay. In such circumstance, you would only be responsible for your plan’s in-network cost sharing amounts, such as any deductibles, coinsurance or copayments.
- Maryland law also protects you if you have to go to the hospital and you receive care from an out-of-network on-call physician or out-of-network hospital-based physician.
- Michigan law protects you from balance billing and requires you to only pay your in-network cost sharing amounts for:
- Covered emergency services provided by and out-of-network provider at an in-network facility or out-of-network facility;
- Covered nonemergency services provided by and out-of-network provider at an in-network facility if you not have the ability or opportunity to choose an in-network provider; and
- Any healthcare services provided at in-network facility from an out-of-network provider within 72 hours of a patient receiving services from that facility’s emergency room.
- If an out-of-network provider accepts assignment of your insurance benefit, the provider cannot balance bill you for any amount that exceeds your in-network cost-sharing requirement other than the applicable deductible or copayment.
- Mississippi’s balance billing prohibition above covers enrollees of (i) health maintenance organizations and (ii) insurance companies or any other entity responsible for the payment of benefits under a policy or contract of accident and sickness insurance in Mississippi.
- Nebraska law provides protection through their Out-of-Network Emergency Medical Care Act which provides balance billing protections to patients receiving out-of-network emergency care from providers at particular facilities.
- Nevada balance billing prohibition protects you if you are covered by health benefit plans regulated by the state, the Public Employee’s Benefits Program, and third parties that opt into the prohibition from balance billing for medically necessary emergency services provided by an out-of-network provider.
- An out-of-network provider may not balance bill you (if enrolled in a health maintenance organization plan or preferred provider organization plan) for emergency services received from such out-of-network provider at an out-of-network facility or ambulance. You will only have to pay your in-network cost sharing.
- Ohio law also protects you (if enrolled in a health maintenance organization plan or preferred provider organization plan) from surprise medical bills when you receive unanticipated out-of-network care at an in-network health facility and such services would be covered if provided by an in-network provider. You will only have to pay your in-network cost sharing.
- An out-of-network provider cannot bill you an amount that exceeds your in-network cost-sharing requirement other than the applicable deductible or copayment for (i) emergency services, (ii) nonemergency services provided by out-of-network providers at in-network facilities, or (iii) diagnostic imaging or laboratory services performed by an out-of-network provider in connection with a service performed by an in-network provider.
- If you have signed a balance billing waiver and elected to be responsible for the provider’s billed charges, an out-of-network provider may be allowed to balance bill you. The written waiver must disclose that the provider is out-of-network, provide an estimate of the amount you may be responsible for, and the circumstances under which you would be responsible for those amounts.
- A balance billing waiver cannot be used in an emergency or when you did not have a meaningful choice in providers.
- Texas’s balance billing prohibition above covers enrollees of Texas state-regulated fully insured health plans.
Please note there are no balance billing protections under Alabama, Hawaii, South Carolina, Tennessee, Pennsylvania, or Wisconsin law. However, you may still be protected under these federal balance billing prohibitions, and the Pennsylvania Insurance Department has taken responsibility for implementing federal protections within Pennsylvania.
If you believe you’ve been wrongly billed, you may contact:
- California Department of Insurance at 1-800-927-4357, the California Department of Managed Health Care at 1-888-466-2219 or visit https://www.dmhc.ca.gov/FileaComplaint.aspx to file a complaint;
- Colorado Department of Regulatory Agencies, Division of Insurance, Consumer Services Division at 303-894-7490 or DORA_Insurance@state.co.us for more information or to file a complaint;
- Indiana Department of Insurance at 1-800-622-4461 or 1-317-232-2395 for more information or to file a complaint;
- Iowa Insurance Division at 1-515-654-6600 for more information or to file a complaint;
- Maryland Insurance Administration at 410-468-2000 or call 1-800-492-6116 to file a complaint;
- Michigan Department of Insurance and Financial Services at 877-999-6442 for more information or to file a complaint;
- Mississippi Insurance Department at 1-800-562-2957 or file a complaint with the Mississippi Attorney General’s Office-Consumer Protection Division at https://www.ago.state.ms.us/divisions/consumer-protection/consumer-complaint-form/;
- Nebraska Department of Insurance at 1-877-564-7323 for more information and to file a complaint;
- Department of Business and Industry, Nevada Division of Insurance at 1-888-872-3234 for more information and to file a complaint;
- Ohio Department of Insurance at 1-800-686-1526 for more information and to file a complaint;
- Pennsylvania Insurance Department’s Consumer Services Bureau at 1-877-881-6388 or visit https://paebrprod.powerappsportals.us/EBR/PID/No-Surprises-Bill-Review-Request-Form/ to submit a No Surprises Bill Request Form; or
- Texas Department of Insurance at 1-800-252-3439 or visit https://www.tdi.texas.gov/medical-billing/surprise-balance-billing.html.
For more information about your rights under the relevant state law, visit the following state websites:
- http://www.insurance.pa.gov/NoSurprises; and