No Surprise Billing

When you receive emergency care at an out-of-network facility or are treated by an out-of-network provider at an in-network hospital, the laws protect you from surprise or balance billing.
• Surprise billing (sometimes called “balance 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.
• If you receive services from an out-of-network provider at an in-network facility, you can’t be balance billed unless you have given your prior written consent.
If you believe you’ve been wrongly billed
• Ohio residents: Contact the Ohio Department of Insurance at 800.686.1526, or visit the Ohio Department of Insurance for more information about your rights under Ohio state laws.
• Florida residents: Contact the Florida Office of Insurance Regulation at 850.413.3140, or visit the Florida Office of Insurance Regulation for more information about your rights under state laws.
For more information about your rights under federal law, visit the Centers for Medicare & Medicaid Services website. Continue reading for complete information regarding your protections against balance billing.
What Is Balance Billing?
When you see a doctor or other healthcare provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, 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 isn’t in your health plan’s network.
Out-of-network describes providers and facilities that haven’t signed a 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 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.
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 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.
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 services provided by: emergency medicine, anesthesiology, pathology, radiology, laboratory, neonatology, assistant surgeons and hospitalists or intensivists. 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.
• Your health plan generally must:
o Cover emergency services without requiring you to get approval for services in advance (prior authorization).
o Cover emergency services by out-of-network providers.
o 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.
o Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
Frequently Asked Questions
How do I estimate how much my procedure will cost?
Contact the office of Premier Mental Health LLC to receive an estimate for your services. 216.273.4003