WHATIS“BALANCEBILLING”SOMETIMES
CALLED“SURPRISE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 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 aer
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.
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.
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 an in-network hospital
or ambulatory surgical center, out-of-network
providers can’t balance bill you, unless you give
written consent and give up your protections.
YOUHAVETHERIGHTTORECEIVEA“GOOD
FAITHESTIMATEOFCHARGES”
You may ask for an estimate of the amount that
you will be charged for a nonemergency medical
service provided by a healthcare facility or
practitioner. If you are uninsured or intending
to pay for the service out of pocket, federal law
requires that a provider or facility provide you
with an estimate for all scheduled nonemergency
healthcare services at least one business day before
the services are to be performed.
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.
YOURRIGHTSANDPROTECTIONS
AGAINSTSURPRISEMEDICALBILLS
Kentucky (01.22)
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 think you’ve been wrongly billed, contact
the Centers for Medicare and Medicaid Services at
800.985.3059.
Visit https://www.cms.gov/nosurprises/consumers
for more information about your rights under
federal law.
YOURRIGHTSANDPROTECTIONS
AGAINSTSURPRISEMEDICALBILLS
Kentucky (01.22)