Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or are treated by an out-of-network provider
at an in-network facility, you are protected from surprise billing or
What is “balance billing” (sometimes called “surprise
When you see a doctor or other healthcare 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 healthcare 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.
Insurers are required to tell you which providers and facilities are in
their networks. Providers and facilities must tell you with which provider
networks they participate. This information is on the insurer’s,
provider’s or facility’s website or on request.
You are protected from balance billing for:
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 deductibles, copayments and coinsurance). You
can’t be balance billed for these emergency services. This includes services
at the same facility that 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 facility
When you get services from an in-network facility, 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, laboratory, surgeon and assistant surgeon services,
and professional ancillary services such as anesthesia, pathology, radiology,
neonatology, hospitalist, or intensivist services. These providers
can’t balance bill you and
can’t ask you to give up your protections not to be balance billed.
If you receive other services at these in-network facilities, out-of-network
can’t balance bill you, unless you give written consent and give up your protections.
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 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
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
- Count any amount you pay for emergency services or out-of-network services
toward your in-network deductible and in-network out-of-pocket limit.
If you believe you’ve been wrongly billed, you may call the federal agencies responsible for enforcing the federal
balance billing protection law at:
1-800-985-3059 and/or file a complaint with the Virginia State Corporation Commission
Bureau of Insurance at:
scc.virginia.gov/pages/File-Complaint-Consumers or call
cms.gov/nosurprises for more information about your rights under federal law.
Consumers covered under (i) a fully-insured policy issued in Virginia,
(ii) the Virginia state employee health benefit plan; or (iii) a self-funded
group that opted-in to the Virginia protections are also protected from
balance billing under Virginia law. Visit
scc.virginia.gov/pages/Balance-Billing-Protection for more information about your rights under Virginia law.
You have the right to receive a "Good Faith Estimate" explaining
how much your medical care will cost.
Under the law, healthcare providers need to give patients who don't
have insurance or who are not using insurance an estimate of the bill
for medical items and services.
- You have the right to receive a Good Faith Estimate for the total expected
cost of any non-emergency items or services. This includes related costs
like medical tests, prescription drugs, equipment, and hospital fees.
- Make sure your healthcare provider gives you a Good Faith Estimate in writing
at least 1 business day before your medical service or item. You can also
ask your healthcare provider, and any other provider you choose, for a
Good Faith Estimate before you schedule an item or service.
- If you receive a bill that is at least $400 more than your Good Faith Estimate,
you can dispute the bill.
- Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit
www.cms.gov/nosurprises or call