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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 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. 

Pennsylvania: The Pennsylvania Insurance Department coordinates implementation of federal law for Pennsylvania patients. If you receive a surprise medical bill for services provided in Pennsylvania, contact the PA Insurance Department with questions or to file a balance billing complaint. 

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 (also known as “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 in-network deductible and out-of-pocket limit.

Contact the federal phone number for information and complaints: (800) 985-3059; or visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.

For services provided in Pennsylvania: visit http://www.insurance.pa.gov/NoSurprises for more information about Pennsylvania enforcement of the federal law. For additional questions, call the PA Insurance Department at: (877) 881-6388 or TTY/TDD at: (717) 783-3898.

The good faith estimate outlines an uninsured (or self-pay) individual’s expected charges for a scheduled or requested item or service by a healthcare provider. The good faith estimate will also include items or services reasonably expected to be provided. If you are insured, you may also request a good faith estimate of the amount you will be billed for services you might like to schedule. For more information on good faith estimates, please visit: https://www.cms.gov/medical-bill-rights/help/guides/good-faith-estimate