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 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, like a copayment, coinsurance, or deductible. You may have additional 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" means providers and facilities that haven't signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays 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 plan's deductible or 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. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

You're 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 (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 balance 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 can 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 types of 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 out-of-network care. You can choose a provider or facility in your plan's network.

Your protections under New Jersey law

If you receive services in New Jersey, the New Jersey Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act gives you additional protections. Out-of-network providers and facilities are prohibited from billing you more than your plan's in-network cost-sharing amount (your deductible, copayment, or coinsurance) for:

• Emergency or urgent services provided by an out-of-network provider or facility; and
• Inadvertent out-of-network services — covered services provided by an out-of-network provider at an in-network facility when in-network services are unavailable, including laboratory testing ordered by an in-network provider.

In these situations, your insurance benefits are automatically assigned to the provider, so you don't have to take any action, and any payment dispute is resolved between the provider and your health plan rather than billed to you. Before any scheduled, non-emergency service, you also have the right to be told whether your provider is in-network or out-of-network with your plan.

These New Jersey protections apply to New Jersey-regulated health plans — including fully insured plans, the State Health Benefits and School Employees' Health Benefits programs, and self-funded plans that opt in. They do not apply to Medicare, Medicaid, or Medicare Advantage. For more information, contact the New Jersey Department of Banking and Insurance at 1-800-446-7467 or visit the Department's Out-of-Network Consumer Protections page.

When balance billing isn't allowed, you also have these protections:

• You're only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
• Generally, your health plan 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 it would pay an in-network provider or facility and show that amount in your explanation of benefits; and count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

If you think you've been wrongly billed, contact the No Surprises Help Desk at 1-800-985-3059. Visit cms.gov/nosurprises/consumers for more information about your rights under federal law.

Your Right to a Good Faith Estimate

You have the right to receive a "Good Faith Estimate" explaining how much your medical care will cost.

Under the law, health care providers need to give patients who don't have insurance or who are not using insurance an estimate of the expected charges for medical services, including items like medical tests, prescription drugs, equipment, and hospital fees.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.
• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit cms.gov/nosurprises or call 1-800-985-3059.