When you see a doctor, health care provider and/or visit a healthcare facility, you may owe certain out-of-pocket costs such as co-payment, co-insurance and/or deductible. You may also have other costs or be responsible for the entire bill if you see a provider or visit a healthcare facility that is not in your health insurance network. It is important that you contact your health insurance to understand whether your services are in-network or out-of-network.
If you have health insurance and get care from an out-of-network provider or at an out-of-network facility, your health plan may not cover the entire out-of-network cost. “Out-of-network” describes providers and facilities that have do not have a signed contract with your health insurance 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 higher than in-network costs for the same service and might not count toward your annual out-of-pocket limit. This can leave you with higher costs than if you got care from an in-network provider or in-network healthcare facility. In the past, in addition to any out-of-network cost sharing you might owe, the out-of-network provider or facility could bill you for the difference between the billed charge and the amount your health plan paid, unless banned by state law. This is called “balance billing.”
If you get health coverage through your employer, the Health Insurance Marketplace®, or an individual health insurance plan you purchase directly from an insurance company, these new rules will:
- For Emergency Care: Limit the amount billed to your plan’s in-network cost-sharing amount (such as co-payments and co-insurance) for certain services, i.e., emergency services and those services used to stabilize you. You may not be balance billed for these emergency services, even if you get them at an out-of-network facility or by an out-of-network provider, and without approval beforehand (prior authorization).
- Limit your bill to your plan’s in-network cost-sharing amount (such as co-payments and co-insurance) for some non-emergency services that are provided to stabilize you after an emergency visit.
- Planned/Scheduled Visits: In non-emergency situations, if you are out-of-network with the facility, you will be informed that the facility is not in your insurance network before your service is scheduled. If the facility is in-network, but one of the providers may not be (like an anesthesiologist, for example) you will be informed the provider is out-of-network before your procedure or services. You can’t be charged more than in-network cost-sharing (such as co-payments or co-insurance) for these services if there is no alternative in-network provider available.
- Require that health care providers and facilities give you an easy-to-understand notice explaining that getting care out-of-network could be more expensive and options available to you to avoid balance bills. You’re not required to sign this notice or get care out-of-network. You may choose a provider or medical facility in your plan’s network.
- For Non-Emergency Care: If your insurance does not have any in-network facilities, you may be charged full charges for Planned/Scheduled visits. It is important for you to talk to your health insurance provider to understand who they have network agreements with, and arrange your care with in-network facilities and providers, if available.
If you don’t have insurance or you choose to pay for care without using your insurance (also known as “self-paying” for care), these new rules make sure you can get a “good faith estimate" of how much your care will cost, before you get care.
For more information about these policies and consumer protections, see CMS.gov