Your Rights and Protections Against Surprise Medical Bills
What is “balance billing” (sometimes called “surprise billing”)?
When you get care from a doctor, hospital or other health care professional, you may owe certain out-of-pocket costs, such as a copay, coinsurance and/or a deductible. You may have other costs — or have to pay the entire bill — if you get care from a doctor, hospital or other health care professional that isn’t in your health plan’s network, also called “out of network.”
“Out of network” describes doctors, hospitals and other health care professionals that haven’t signed a contract with your health plan to participate in its network of providers. Out-of-network providers may be permitted to bill you for the difference between what your health plan may pay based on your health plan’s out-of-network benefits and the full amount charged by the out-of-network provider 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.
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 health plan’s in-network cost sharing amount (such as copays and coinsurance). You can’t be balance billed for any amount in excess of your in-network cost sharing amount for any 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 balance billed for the services once you are stabilized. Out-of-network doctors, hospitals and other health care professionals are not permitted to seek your consent for the out-of-network services before providing the emergency services or during the time you are being stabilized.
When you get certain non-emergency services at an in-network hospital or ambulatory surgical center, certain providers at the facility may be out of network. Unless you give proper consent to get care from an out-of-network provider and waive your balance billing protections, the most an out-of-network provider may bill you is your health plan’s in-network cost sharing amount. This applies but is not limited to such providers as anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist or intensivist services. If proper consent is not provided, these providers can’t balance bill you for their surprise services.
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 health plan’s network.
There are state and federal laws to help protect you against surprise medical bills, as described above.
New Jersey Law
New Jersey’s law, the Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act (New Jersey OON Mandate), was effective August 30, 2018.
This law applies to fully insured individual and group health insurance plans, as well as those self-funded employer groups that have specifically opted into this mandate. It also applies to the State Health Benefits Program/School Employees’ Health Benefits Program.
The Consolidated Appropriations Act, 2021 (CAA) was signed into law on December 27, 2020. The CAA includes a provision known as the No Surprises Act, which establishes protections from surprise billing, effective January 1, 2022. The No Surprises Act offers protections that are similar to the New Jersey OON Mandate and applies to those surprise bills not subject to the New Jersey OON Mandate, including bills for care provided outside of New Jersey and air ambulance services, if air ambulance is a covered benefit under a health plan’s contract.
The No Surprises Act applies to self-funded employer groups who did not opt-in to the New Jersey OON Mandate, as well as the Federal Employee Program (FEP). It also applies to fully insured members, the State Health Benefits Program/School Employees’ Health Benefits Program, and those ASO groups who opted into the New Jersey OON Mandate, when services are not covered by the New Jersey OON Mandate.
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 copays, coinsurance and deductibles that you would pay if the doctor, hospital or other health care professional was in network). Your health plan will pay out-of-network doctors, hospitals and other health care professionals directly.
- Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (also called prior authorization).
- Cover emergency services provided by out-of-network doctors, hospitals and other health care professionals.
- Base what you owe the out-of-network doctor, hospital or other health care professional (also called your cost sharing) on what it would pay an in-network doctor, hospital or other health care professional, 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.
Federal No Surprises Act: If you think you’ve been billed wrong, you can contact Horizon or call the No Surprises Help Desk at 1-800-985-3059. You can also visit cms.gov to submit a complaint online.