Your Rights and Protections Against Surprise Medical Bills

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 co-payment, coinsurance, or deductible. You may have extra 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” means providers and facilities that haven’t signed a contract with your health plan to give services. Out-of-network providers may be able to bill you for the difference between what your plan pays and the full amount they charge for a service. This is called “balance billing.”

This amount is often more than in-network costs for the same service. It might not count toward your plan’s deductible or annual out-of-pocket limit.

“Surprise billing” is a balance bill you don’t expect. This can happen when you can’t control who provides your care, like when you have an emergency. It can happen when you schedule a visit at an in-network facility, but an out-of-network provider treats you. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

You are protected from balance billing for emergency services.

If you have a medical emergency and get emergency care from an out-of-network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount. (This includes copayments, coinsurance, and deductibles.) You can’t be balance billed for emergency services.

They also cannot balance bill you for the care you may get after you’re in stable condition. You can only be balance billed if you give written consent to give up your protection against balance billing for care after you are stable.

You are also protected from balance billing for 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. 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, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you. They cannot ask you to give up your protections against balance billing.

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 protection.

You are 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 only need to pay 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 other costs to out-of-network providers and facilities directly.

In Minnesota, Essentia Health cannot bill you more than what your health plan has agreed to pay for services per our contract with them. You will need to pay the approved co-payment, coinsurance, or deductible. Essentia may bill you for services not covered by your health plan with your advance consent.

In general, 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 providers.
• Base what you owe the provider or facility on what it would pay an in-network provider or facility. Your health plan must show that amount in your explanation of benefits.
• Cover 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:

• Visit www.cms.gov for more information about your rights under federal law. The federal phone number for information and complaints is (800) 985-3059.
• If you received care in Minnesota, you may contact the Office of Minnesota Attorney General at:
  • 445 Minnesota Street, Suite 1400
    St. Paul, MN 55101
    (800) 657-3787 or (800) 627-3529 (Minnesota Relay)