No Surprise Billing Act

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you should not 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, like a copayment, coinsurance, or deductible. If you see a provider or visit a facility that is not in your health plan’s network, you may have additional costs or be billed for the entire amount. Out-of-network providers may bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.”

“Surprise billing” is an unexpected balance bill. This can happen when you cannot control who is involved in your care—such as during an emergency or when you receive treatment at an in-network facility but are unexpectedly cared for 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 they can bill you is your plan’s in-network cost-sharing amount. This includes post-stabilization services, unless you give written consent to be billed out-of-network.
• Certain services at an in-network hospital or ambulatory surgical center – When you receive care at an in-network facility, some providers there may still be out-of-network. In these cases, those providers cannot balance bill you for:
  
  • Emergency medicine
  • Anesthesia
  • Pathology
  • Radiology
  • Laboratory
  • Neonatology
  • Assistant surgeon
  • Hospitalist or intensivist services

These providers cannot ask you to waive your protections. You are never required to give up your protections from balance billing.

When balance billing is not allowed, you are only responsible for:

• Your share of the costs (copayments, coinsurance, deductibles) as if the provider or facility was in-network.
• Your health plan must pay out-of-network providers/facilities directly for any additional costs.

Generally, your health plan must:

• Cover emergency services without requiring prior authorization.
• Cover emergency services by out-of-network providers.
• Base what you owe the provider/facility on in-network costs and show that in your Explanation of Benefits.
• Count any amounts you pay toward your in-network deductible and out-of-pocket limit.

If you believe you have been wrongly billed:

• Contact ONYX Spine & Orthopedics at (314) 266-2066.
• You can also contact the federal No Surprises Help Desk at 1-800-985-3059.
• More information about your rights is available at: www.cms.gov/nosurprises/consumers

Additional Resources: