Billing

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. 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, suchas a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay theentire 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 healthplan. Out-of-network providers may be permitted to bill you for the difference between what yourplan agreed topay, and the full amount charged for a service. This is called “balance billing.” Thisamount is likely more than in-network costs for the same service and might not count toward yourannual out-of-pocket limit.“Surprise billing” is an unexpected balancebill. This can happen whenyou can’t control who is involved in your care, like when you have an emergency or when youschedule 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, deductibles, 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.
• Utah state law also protects you from balance billing for emergency 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 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.
• You’re never required to give up your protections from balance billing. You also aren’t required toget care out-of-network. You can choose a provider or facility in your plan’s network.
• Utah statelaw also states that you may not be held responsible for more than your health plan in-network cost share.

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
• 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:

Your health plan: You can ask them why you got the bill and if it is accurate. For emergency services, verify your health plan processed the claim as emergent.

Utah Insurance Department:‍

Phone: (800) 439-3805 or (801) 957-9280

Email: health.uid@utah.gov
Visit https://insurance.utah.gov/consumer/health/no-surprises-act for more information about your rights under Utah state law.

U.S. Centers for Medicare & Medicaid services

No Surprises Help Desk: (800) 985-3059

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

Good Faith Estimate:

You have the right to receive a “GoodFaith Estimate” which explains how much your medical care may cost.

Under the No Surprises Act when requested providers are to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. You have the right to receive a Good Faith Estimate of the total expected costs for non-emergent services.

This must be presented from the provider at least one business day prior to the date of service. If you receive a bill that is at least $400.00 more than your Good Faith Estimate you can dispute the bill.

Note: You could be charged more than the estimated amount if you receive additional items during the visit or procedure that were not anticipated.Be sure to maintain a copy of the Good Faith Estimate for your records. More information on this can be found at https://www.cms.gov/nosurprises

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