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 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 if you see a provider or visit a health care facility that isn’t in your health insurance network.
“Out-of-network” means providers, hospital, or clinics that haven’t signed a contract with your health insurance company. Out-of-network providers may bill you for the difference between what your health insurance 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 have less control over who is involved in your care—like when you have an emergency or when you visit an in- network facility but are unexpectedly treated by an out-of-network provider.
In Massachusetts, you are protected from balance or “surprise” billing
Health care providers must:
- Inform you if they are out-of-network prior to your appointment or admission.
- Inform you, if you request it, of the amount that you will be charged for admission, a procedure, or a service, including costs for services done by an out-of-network provider.
- Notify you when you are referred to an out-of-network provider.
- Not bill insured patients more than the typical, applicable coinsurance, copayment, or deductible that would have been charged if services were provided by an in-network provider.
Federal law also protects you from balance/surprise billing for:
- Emergency services
If you have an emergency medical condition and get emergency services from an out-of-network provider/hospital/clinic, the most the provider/hospital/clinic may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance/surprise 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 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 surprise 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 surprise 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 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 hospital/clinic was in-network). Your health plan will pay out-of-network providers and hospitals/clinics 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 hospital/clinic (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 Patient Billing at 857-654-1000. If you think you’ve been sent a surprise bill you should not have to pay, contact your insurer to file a complaint. Then file a complaint with the Massachusetts Attorney General either online or by calling 1-888-830-6277. You can also contact Health Law Advocates at 888-211-6168 for free legal advice or assistance. Visit this link for more information about your rights under Massachusetts laws. Visit this link for more information about your rights under federal law.