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")?
"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.
When you see an in-network doctor or other health care provider who have already contracted with your insurance carrier, you may owe certain out-of-pocket costs, such as a co-payment, co-insurance, and/or a deductible based on your insurance plan. 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.
But when you see an "out-of-network" provider or facility who haven’t signed a contract with your health plan, they 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.
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 co-payments and co-insurance). 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 cannot 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.
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 co-payments, co-insurance, 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 or wish additional information, you may visit the Centers for Medicare & Medicaid Services (CMS) online or call 1-800-985-3059.
Virginia Patients may also file a complaint with the Virginia State Corporation Commission Bureau of insurance online or call 1-877-310-6560.
Maryland Patients may also file a complaint. See Maryland-specific balance billing protections for more information.
- Maryland-specific balance billing protections
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If you are in a Health Maintenance Organization (HMO) governed by Maryland law, you may not be balance billed for services covered by your plan, including ground ambulance service If you are in a PPO or EPO governed by Maryland law, hospital-based or on-call physicians paid directly by your PPO or EPO (assignment of benefits) may not balance bill you for services covered under your plan and can’t ask you to waive your balance billing protections.
If you use ground ambulance services operated by a local government provider who accepts an assignment of benefits from a plan governed by Maryland law, the provider may not balance bill you.
You also have these protections:
- You’re only responsible for paying your share of the cost (like the co-payments, co-insurance, 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.
- Generally, your health plan 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 in-network deductible and out-of-pocket limit.
If you think you have been wrongly billed, you may contact the Health Education and Advocacy Unit (HEAU) of Maryland’s Consumer Protection Division:
Health Education and Advocacy Unit
Office of the Attorney General
200 St Paul Place, 16th Floor
Baltimore, Maryland 21202
Phone: 410-528-1840 or toll-free 1-877-261-8807
En español: 410-230-1712
Fax: 410-576-6571
Email: heau@oag.state.md.us
Health Education and Advocacy Unit WebsiteIf you think your health plan processed your claim incorrectly, you may contact the Maryland Insurance Administration:
Maryland Insurance Administration
Life and Health Complaints Unit
200 St Paul Place, Suite 2700
Baltimore, Maryland 21202
Phone: 410-468-2000 or toll free 1-800-492-6116
Fax: 410-468-2260
Maryland Insurance Administration Website