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 haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full 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 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 when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You are 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 facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). 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.
The Out-of-network Consumer Protection, Transparency, Cost Containment, and Accountability Act, (P.L.2018, c.32), (“Act”), was signed into law on June 1, 2018, and became effective on August 30, 2018. This Act provides enhanced protections for consumers who receive health care services from out-of-network providers under the circumstances described below. These enhancements include:
- transparency and various disclosure requirements by providers and carriers;
- the creation of an arbitration system for out-of-network payment disputes; and
- protections for consumers for certain out-of-network bills.
The Department of Banking and Insurance issued Bulletin No. 18-14 on November 20, 2018 to provide guidance to carriers, health care providers, and other interested parties to help those entities meet their obligations under the Act, pending the adoption of rules.
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 may 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 not to be balance 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 protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
The Out-of-network Consumer Protection, Transparency, Cost Containment, and Accountability Act, (P.L.2018, c.32), (“Act”), was signed into law on June 1, 2018, and became effective on August 30, 2018. This Act provides enhanced protections for consumers who receive health care services from out-of-network providers under the circumstances described below. These enhancements include:
- transparency and various disclosure requirements by providers and carriers;
- the creation of an arbitration system for out-of-network payment disputes; and
- protections for consumers for certain out-of-network bills.
The Department of Banking and Insurance issued Bulletin No. 18-14 on November 20, 2018 to provide guidance to carriers, health care providers, and other interested parties to help those entities meet their obligations under the Act, pending the adoption of rules.
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 copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
- Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in
advance (prior authorization). - Cover emergency services by out-of-network provider
- 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 deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, please contact your carrier at the number below or the number on your ID card. If the issue is not resolved, you can also contact Health and Human Services (HHS) and/or the State of New Jersey Department of Banking & Insurance (DOBI).
Carriers –
HHS –
1-800-985-3059
NJ DOBI –
609-292-7272 or Consumer Hotline 1-800-446-7467
Visit www.cms.gov/nosurprises/consumers for more information about your rights under
federal law.
Visit www.state.nj.us/dobi/consumer.htm for more information about your rights under New
Jersey law.
