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 balance billing (sometimes called surprise billing).

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 outof-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 innetwork 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 costsharing 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 balance billed for these poststabilization services.  New Jersey law also protects you from being billed for inadvertent out-of-network services (services at an in-network facility provided by out-of-network providers) in an amount in excess of your in-network cost-sharing amount (i.e., the amount your deductible, copayments, or coinsurance would have been if the same services were provided on an in-network basis). “Pursuant to NJ state law A2039, members are not liable for full payment of inadvertent, emergent or involuntary charges from out-of-network providers, and members cannot be billed for amounts above their costs for in-network 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 may be out-of-network. In these cases, the most those providers may bill you is your plan's innetwork 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 to get care out-of-network. You can choose a provider or facility in your plan's network. New Jersey law also protects you from being billed for inadvertent out-of-network services (services at an in-network facility provided by out-of-network providers) in an amount in excess of your innetwork cost-sharing amount (i.e., the amount your deductible, copayments, or coinsurance would have been if the same services were provided on an in-network basis). “Pursuant to NJ state law A2039, members are not liable for full payment of inadvertent, emergent or involuntary charges from out-of-network providers, and members cannot be billed for amounts above their costs for in-network services.”

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 outof-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 Centers for Medicare & Medicaid Services, Department of Health and Human Services at 800-985-3059. For services rendered in New Jersey, you also may contact the New Jersey Department of Banking and Insurance at 609-292-7272 or file an online complaint at: NJDOBI | How To Request Assistance - Consumer Inquiries and Complaints (state.nj.us) 

For more information about your rights under federal law, visit: https://www.cms.gov/nosurprises/consumers. For more information about your rights under New Jersey law, visit: New Jersey Department of Banking and Insurance (state.nj.us)