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YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS (OMB Control Number: 0938-1401) When you receive emergency care or receive treatment by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
“Balance Billing” (otherwise known as “Surprise Billing”) When you see a doctor or other healthcare provider for treatment, you may be charged 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 when you are uninsured or receive treatment from a provider or facility that is not in your insurance plan’s network.
“Out-of-network” describes providers and facilities that have not signed a contract with your insurance 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 be applied towards your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you cannot control who is involved in your care. An example is as follows: you may experience a medical emergency, present to an in-network facility for treatment, but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for: Emergency Services If you have an emergency medical condition and receive emergency services from an out-of-network provider or facility, then the most the provider or facility may bill is your insurance plan’s in-network cost-sharing amount such as copayments and coinsurance. You cannot be balance billed for these emergency services. Unless you provide written consent relinquishing your protections against balance billing, you may be billed for services you may receive after you are in stable condition and post-stabilization services. If you knowingly choose an out-of-network provider for your care, then it is not considered a surprise medical bill. For additional information from the Commonwealth of Pennsylvania, please review the below information found on the state’s website. https://www.insurance.pa.gov/Coverage/health-insurance/no-surprises-act/Pages/FAQs.aspx
Servicesatanin-networkhospital orambulatorysurgicalcenter If you receive treatment from an in-network hospital or ambulatory surgical center, then certain providers at the facility may be out-of-network. In these cases, the most those providers may bill 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 cannot balance bill you and may not askyou to relinquish your protections against balance billing. If you receive other services at these in-network facilities, then out-of-network providers cannot balance bill you unless you give written consent and relinquish your protections.
You are never required to give up your protection from balance billing. You are not required to receive out-of-network care. You can choose a provider or facility in your insurance plan’s network.
When balance billing is not allowed, you also have the following protections: With emergency services, you are only responsible for paying your share of the cost such as copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network. Your insurance plan will pay out-of-network providers and facilities directly.
Generally, your insurance plan is required to: 1. Cover emergency treatment services without requiring you to obtain approval for services in advance. 2. Cover emergency treatment services by out-of-network providers. 3. With emergency treatment, base what you owe the provider or facility (cost-sharing) on what the insurance company would pay an in-network provider or facility. This amount must also be communicated in your explanation of benefits. 4. Deduct any amount you pay for out-of-network emergency services toward your deductible and out-of-pocket limit.
If you believe you have been wrongly billed, then you may contact Consumer Services online at www.insurance.pa.gov or by calling 1.877.881.6388 or TTY/TDD 1.717.783.3898