Because you matter.

Your Rights and Protections Against Surprise Medical Bills

 

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

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, 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 health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that have not signed a contract with your health plan. Out-of-network providers may be allowed to bill you for the difference between what your plan agreed to pays and the full amount charged for a service. This is called “balance billing.” This amount is usually 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 cannot 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.

You never have to give up your protection from balance billing. You also do not have to obtain care out-of-network. You can choose a provider or facility in your plan’s network.

When balance billing is not 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 were in-network). Your health plan will pay out-of-network providers and facilities directly.

Your health plan, in general, 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 an in-network provider or facility would pay 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.
  

If you believe you have been wrongly billed, you may contact: The North Carolina Board of Licensed Clinical Mental Health Counselors.

Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf  and the government's website for more information about your rights under Federal law.  

You can print out a copy of this notice here.