No Surprise Billing

Your Rights and Protections Against Surprise Medical Bills

You are protected from balance billing when you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

What is “Balance Billing” (or “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 charges 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” 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 total 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 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: 

Emergency services

Suppose you have an emergency medical condition and get emergency services from an out-of-network provider or facility. In that case, 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.

Tennessee law requires MLH to notify you regarding state-level balance billing protections. You will receive a separate form with this information.

Specific 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 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 to be balanced billed. 

If you get other 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 protection 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.

Tennessee law requires MLH to notify you regarding state-level balance billing protections. You will receive a separate form with this information.

When balance billing isn’t allowed, you also have these protections:

• You’re only responsible for paying your share of the cost (ex. the copayments, coinsurance, and deductible that you would pay if the provider or facility were in-network). Your health plan will pay any additional costs directly to out-of-network providers and facilities.
  
  
• Generally, your health plan must:
  
  1. Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
  
  2. Cover emergency services by out-of-network providers.
  
  3. 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.
  
  4. 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 the Centers for Medicare & Medicaid Services at 1-800-985-3059. Contact the Tennessee Department of Commerce & Insurance at 615-741-2241. Contact the Tennessee Department of Health at 615-741-7221.

Visit www.cms.gov/nosurprises for more information about your rights under federal law.

Visit https://www.tn.gov/health.html and/or https://www.tn.gov/commerce/insurance-division.html for more information about your rights under Tennessee law.