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:
- 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. 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.
- State protections against balance billing – You may also be protected under Florida law for emergency services that you receive. The most you can be billed by the providers is your in-network copayments, deductibles, and/or coinsurance. If you are protected under Florida law, you cannot be balance-billed in Florida for any other amount by either the emergency facility where you receive emergency services or any providers that see you for emergency care.
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.
Under Florida law, you cannot be balance billed if you receive covered services from out-of-network providers at an in-network facility. In such case, the most you can be billed for covered services is your in-network co- payments, deductibles, and/or coinsurance. If, however, you do have the ability and opportunity to choose an in-network provider at the facility, and you chose an out-of-network provider, you may be balance billed or you may be responsible for the entire bill. Please note that Florida law does NOT apply to all health plans. If Florida law does not apply, you may still be protected under Federal balance billing prohibitions.
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 Department of Health and Human Services No Surprises Help Desk at: 1 (800) 985-3059. You may also contact Florida Office of Insurance Regulation at firstname.lastname@example.org. To file a complaint with the Office of the Florida Attorney General, visit http://myforidalegal.com/contact.nsf/contact?Open&Section=Citizen_Services/.
Visit https://www.cms.gov/nosurprises for more information about your rights under Federal law.
Visit https://www.foridahealthfnder.gov/index.html for more information about your rights under Florida law.
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.