No Surprises Act
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, like a copayment, coinsurance, or deductible. You may have additional 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.
Copayment: is a defined dollar amount a patient pays for medical expenses. With many health plans, a patient pays 100 percent of costs out-of-pocket until they have met their deductible. After meeting the deductible, a patient pays a copayment (often shortened to “copay”).
Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services.
Coinsurance: Your share of the costs of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service. If you have met your $500 deductible and now have a $300.00 bill = $60.00 coinsurance for you to pay.
“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays 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 plan’s deductible or 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. Surprise medical bills could cost thousands of dollars depending on the procedure or service.
You’re 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 they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). 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 can 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 types of 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.
You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have these protections:
- You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities
- Generally, your health plan must:
- Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
- Cover emergency services by out-of-network
- 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
- 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’ve been wrongly billed, contact:
- Boone Health 1-888-538-1535
- The U.S. Centers for Medicare & Medicaid Services (CMS) at 1.800.MEDICARE (1.800.633.4227) or visit https://www.cms.gov/nosurprises/consumers for more information about your rights under federal law.
- You may also contact the Missouri Department of Commerce and Insurance at:
1.800.726.7390 or by visiting https://insurance.mo.gov/
Under the law, health care providers need to give patients who don’t have certain types of health care coverage or who are not using certain types of health care coverage an estimate of their bill for health care items and services before those items or services are provided.
- You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
- If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask.
- If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, 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/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1.800.985.3059.
The federal phone number for information and complaints is: 1.800.985.3059.
You can also file a complaint with the Missouri Department of Commerce and Insurance 1.800.726.7390.
Get More Information:
Boone Health Customer Service 1.888.538.1535
Or click the Frequently Asked Questions (FAQ) button below!