Your Rights and Protections Against Surprise Medical Bills

Your Rights and Protections Against Surprise Medical Bills

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, and/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.

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.

Idaho State law states that all out-of-network providers of emergency services provided to a covered person in an in-network facility under that person’s health benefit plan are prohibited from balance billing the covered person for emergency services. A covered person’s health benefit plan will reimburse an out-of-network provider for emergency services under that person’s health benefit plan at the greater of the following rates for covered benefits: Eighty-five percent (85%) of the reimbursement rate for the nearest in-network provider licensed to provide the services under the covered person’s health benefit plan, or one hundred forty-five percent (145%) of the Medicare payment rate for the same services in the area where the services were provided.

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 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.

Idaho State law requires that balance-billing only be done when you sign an agreement in writing with the provider prior to services. The agreement must state in twice-as-large font as the next information that the provider is out of network, the covered person bears the risk that the covered person’s health benefit plan reimbursement rate for the services may be less than expected, and the covered person agrees to be personally responsible for up to the full amount of the provider’s bill less actual payment, if any, by the covered person’s health benefit plan.

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:
  • 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.
  • 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 Idaho Department of Insurance at Idaho: (800) 721-3272 or https://doi.idaho.gov/.

Visit https://www.cms.gov/nosurprises/consumers for more information about your rights under federal law.

Visit https://legislature.idaho.gov/wp-content/uploads/sessioninfo/2020/legislation/H0515.pdf for more information about your rights under Idaho State law.