Your Rights and Protections Against Surprise Medical Bills
Effective January 2022
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. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.
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 copay, coinsurance, or 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 cost for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unacceptable 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 scheduled 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.
You are protected from balance billing for:
If you have an emergency medical condition and get emergency services for 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, coinsurance, and deductibles). 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.
Applicable Ohio State Balance Billing OCR 3902.50 -.54
This incorporates the Surprises Act, but two differences should be noted:
• Ground Ambulances: Extends to surprise billing by ground ambulances, where the Act’s
protections do not; and
• Applicable to Fully-Insured: Applies only to fully-insured health plans, whereas, the Act covers both fully-insured and self-insured patients.
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.
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.
- Generally, your health plan must:
- Cover emergency services without requiring you 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 (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, you may contact the Magruder Hospital Financial Counselors at (419) 732-4004. The federal phone number for information or complaints is 1-800-985-3059.
Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law or the Ohio Department of Health at 1-800-342-0553.
Transparency in Coverage mandate requires insurers and group health plans to make rate information publicly accessible to members and non-members. As a self-insured group, Magruder Hospital has posted the following link to the carrier’s publicly available machine readable files (MRFS):
No Surprises Act Legislation (medmutual.com)