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Your Rights and Protections Against Surprise Medical Bills
For services provided on or after January 1, 2022
When you receive emergency care or are 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, like 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 is not in your health plan’s network.
“Out-of-network” describes providers and facilities that have not signed a contract with your health plan. 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 the 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.
Washington Patients: Insurers are required to tell you, via their websites or on request, which providers, hospitals and facilities are in their networks. Hospitals, surgical facilities and providers must tell you which provider networks they participate in on their website or on request.
You’re protected against balance billing if: You participate in a commercial or self-funded insurance plan.
You’re protected from balance billing for:
Emergency services: If you have an emergency medical condition and receive emergency services at a hospital emergency department or freestanding emergency department, the most an out-of-network provider or facility may bill you for such emergency services 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 waive your protections against balance billing for these post-stabilization 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, surgeons and assistant surgeons, hospitalists, or intensivist services. These providers cannot balance bill you and cannot 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.
When balance billing is allowed:
Balance billing is allowed when seeking non-emergent care at a healthcare facility that is not in your insurance network.
When balance billing isn’t allowed, you also have the following protections:
– 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 file a complaint with the:
Oregon Division of Financial Regulations
Washington State Office of the Insurance Commissioner
Visit https://www.cms.gov/nosurprises for more information about your rights under federal law.
Visit the Office of the Insurance Commissioner Balance Billing Protection Act website for more information about your rights under Washington state law.
Cash Pay Patients:
You are entitled to a Good Faith Estimate prior to services being rendered. A Good Faith Estimate shows the costs of items and services that are reasonably expected for your healthcare needs for an item or service. The estimate is based on information known at the time the estimate was created.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
If you are billed for more than your Good Faith Estimate, you have the right to dispute the bill. You may contact the healthcare provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to updated the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.
You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.
There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the healthcare provider or facility, you will have to pay the higher amount.
To learn more and get a form to start this process, go to www.cms.gov/nosurprises or call 1-800-985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-800-985-3059.
It is important to keep a copy of your Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.
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