Effective January 1, 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.

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 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.

Your protections from balance billing 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.

Prior to the passage of the federal No Surprises Act, some states enacted certain, more limited balance billing protections.

Iowa law provides that a plan that covers health care services, including emergency services, that is subject to Iowa’s insurance laws and regulations or to the jurisdiction of the Iowa Insurance Commissioner must cover all provider charges for emergency services provided to an individual, including services furnished by an out-of-network provider. Covered emergency services include all services necessary to evaluate and to stabilize an emergency medical condition.

For more information about your rights under Iowa state law, please contact the Iowa Insurance Division.

In Minnesota, state law governs how much patients covered by fully insured commercial plans will pay for certain unauthorized, non-emergency services and unauthorized emergency services.

For more information about your rights under Minnesota state law, please contact the Minnesota Department of Commerce.

Certain services at an in-network hospital or ambulatory service 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.

Additional protections when balance billing isn’t allowed

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 providers
  • Base what you owe the provider or facility (cost sharing) on what the plan 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 No Surprises Act Federal Help Desk at 800-985-3059 or CMS.gov/NoSurprises.