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.

Balance Billing

When you see a doctor or other healthcare provider, you may owe certain out-of-pocket costs, such as a co-payment, co-insurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a healthcare facility that is not 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 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 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.

Patients 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 co-payments and co-insurance). You cannot be balance billed for these emergency services. This includes services you may get after you are in stable condition unless you give written consent and give up your protections not to be balance billed for these 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 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 cannot 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 cannot balance bill unless you give written consent and give up your protections.

You are never required to give up your protections from balance billing. You also are not required to get 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 co-payments, co-insurance, and deductibles 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 generally must cover emergency services without requiring you to get approval for services in advance (prior authorization), and 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; and count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

Good Faith Estimates

If you don’t have health insurance or you plan to pay for healthcare bills yourself, generally healthcare providers and facilities must give you an estimate of expected charges when you schedule an appointment for a healthcare item or service or if you ask for an estimate. This is called a “good faith estimate.”

The good faith estimate shows the list of expected charges for items or services from your provider or facility. Because the good faith estimate is based on information known at the time your provider or facility creates the estimate, it won’t include any unknown or unexpected costs that may be added during your treatment.

Generally, the good faith estimate must include expected charges for:

• The primary item or service
• Any other items or services you’re reasonably expected to get as part of the primary item or service for that period of care

The estimate might not include every item or service you get from another provider or facility, even if some items or services may seem connected to the same service. For example, if you’re getting surgery, the good faith estimate could include the cost of the surgery, anesthesia, lab services, or tests.

In some cases, items or services related to the surgery that are scheduled separately, like certain pre-surgery appointments or physical therapy in the weeks after the surgery, might not be included in the good faith estimate. You’ll get a separate good faith estimate when you schedule those items or services with the provider or facility or if you ask for it.

Providers and facilities must give you the good faith estimate:

• After you schedule a healthcare item or service. If you schedule an item or service at least three business days before the date you’ll get the item or service, the provider must give you a good faith estimate no later than one business day after scheduling. If you schedule the item or service, or ask for cost information about it, at least 10 business days before the date you get the item or service, the provider or facility must give you a good faith estimate no later than three business days after you schedule or ask for the estimate.
• That includes a list of each item or service (with the provider or facility) and specific details, like the healthcare service code
• In a way that’s accessible to you, like in large print, Braille, audio files, or other forms of communication

Providers and facilities must also explain the good faith estimate to you over the phone or in person if you ask, then follow up with a written (paper or electronic) estimate, per your preferred form of communication.

Keep the estimate in a safe place so you can compare it to any bills you get later. After you get a bill for the items or services, if the billed amount is $400 or more above the good faith estimate, you may be eligible to dispute the bill.

If you believe you’ve been wrongly billed, you may contact the West Virginia Offices of the Insurance Commissioner at https://www.wvinsurance.gov/Consumer_Services or by phone at 304-558-3386 or Toll- free in WV: 888-TRY-WVIC.

Visit https://www.wvinsurance.gov/HealthPolicy for more information about your rights under West Virginia law.

Visit https://www.cms.gov/nosurprises/consumers for more information about your rights under federal law, or by calling 800-985-3059..