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 hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn鈥檛 be charged more than your plan鈥檚 copayments, coinsurance and/or deductible.
What is 鈥渂alance billing鈥 (sometimes called 鈥渟urprise billing鈥)?
When you see a doctor or other health care provider, you may owe certain , like a , , or . 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鈥檛 in your health plan鈥檚 network.
鈥淥ut-of-network鈥 means providers and facilities that haven鈥檛 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 鈥渂alance billing.鈥 This amount is likely more than in-network costs for the same service and might not count toward your plan鈥檚 deductible or annual out-of-pocket limit.
鈥淪urprise billing鈥 is an unexpected balance bill. This can happen when you 肠补苍鈥檛 control who is involved in your care鈥攍ike 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.
驰辞耻鈥檙别 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 hospital, the most they can bill you is your plan鈥檚 in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You 肠补苍鈥檛 be balance billed for these emergency services. This includes services you may get after you鈥檙e in a stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services. If your insurance ID card says 鈥渇ully insured coverage,鈥 you 肠补苍鈥檛 give written consent and give up your protections not to be balance billed for 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鈥檚 in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, and intensivist services. These providers 肠补苍鈥檛 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 肠补苍鈥檛 balance bill you, unless you give written consent and give up your protections. If your insurance ID card says 鈥渇ully insured coverage,鈥 you 肠补苍鈥檛 give up your protections for these other services if they are a surprise bill. Surprise bills are when you鈥檙e at an in-network hospital or ambulatory surgical facility and a participating doctor was not available, a non-participating doctor provided services without your knowledge, or unforeseen medical services were provided.
Services referred by your in-network doctor
If your insurance ID card says 鈥渇ully insured coverage,鈥 surprise bills include when your in-network doctor refers you to an out-of-network provider without your consent (including lab and pathology services). These providers 肠补苍鈥檛 balance bill you and may not ask you to give up your protections not to be balance billed. You may need to sign a form (available on the ) for the full balance billing protection to apply.
驰辞耻鈥檙别 never required to give up your protections from balance billing. You also aren鈥檛 required to get out-of-network care. You can choose a provider or facility in your plan鈥檚 network.
When balance billing isn鈥檛 allowed, you also have these protections:
- 驰辞耻鈥檙别 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 any additional costs to 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 (also known as 鈥減rior authorization鈥).
- 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鈥檝e been wrongly billed and your coverage is subject to New York law (鈥渇ully insured coverage鈥), contact the New York State Department of Financial Services at 1-800-342-3736 or surprisemedicalbills@dfs.ny.gov. Visit for information about your rights under state law.
Contact CMS at 1-800-985-3059 for self-funded coverage or coverage bought outside New York. Visit for information about your rights under federal law.