No Surprises Billing Act
Expiration Date: 05/31/2025
When you receive emergency care from an out-of-network provider at an in-network facility, including a hospital or ambulatory surgical center, you are protected from being balance billed by the out-of-network provider.
*What is “balance billing” (also called “surprise billing”)?
When you see a doctor or other health care professional, you may owe certain out-of-pocket costs including co-pays, coinsurance, and/or deductibles. You may also have other costs or even have to pay the entire bill if you see a provider or visit a healthcare facility that is not in your health plan’s network.
“Out-of-network” describes providers or facilities that have not signed a contract with your health plan. Out-of-network providers are permitted to charge you the difference between the amount your plan will pay for services and the total amount charged for the services. This is called “balance billing”. This amount can be significantly higher than the cost if you had seen an in-network provider for the same service and may count differently towards your out-of-pocket costs.
“Surprise billing” is an unexpected balance bill. This can happen when you have no control over who is involved with your care, such as when you are seen on an emergency basis or you schedule services at an in-network facility but are unexpectedly treated by an out-of-network provider.
*You are protected from “balance billing” for:
If you experience a medical emergency and receive services at an in-network facility from an out-of-network provider, the most the provider may bill you is your plan’s in-network cost-sharing amount, including co-pays, coinsurance, and/or deductibles. You cannot be balance billed for these emergency services.
This would include services you may receive after you are in stable condition unless you give your signed consent and give up your protections to be balance billed for these post-stabilization services.
Certain providers and services at an in-network facility
When you receive services at an in-network facility, some providers may be out of network. This applies to emergency medicine, anesthesia services, pathology or radiology services, laboratory, hospitalist, or assistant surgeons. This is not an all-inclusive list and may include other providers. These providers cannot balance bill you and may not ask you to sign a consent to give up your protections. You are never required to give up your protections from balance billing.
*When balance billing is not permitted, you also have the following protections:
You are only responsible for paying your cost share. Your health plan must cover emergency services without requiring approval for services in advance. Your plan must cover emergency services performed by an out-of-network provider. Your plan must count any amount that you pay for emergency services or out-of-network services towards your deductible and out-of-pocket limits. Your plan must base what you may owe the provider or facility on the amount you would pay an in-network provider or facility and show that amount in the explanation of benefits that they supply you.
If you have any questions, please contact Northwest Oral & Maxillofacial Surgery at Arlington Heights Phone Number 847-392-6220. You may also call 800-985-3059 or visit www.cms.gov/nosurprises/consumers/ for more information about your rights under federal law.