Surprise or Balance Billing
Your rights and protections against surprise medical billsYou may owe out-of-pocket costs like a copay, coinsurance, or deductible when you see a doctor or healthcare provider. You may also have other costs or may have to pay the entire bill if you see a provider or visit a health care facility that is not in your insurance plan’s network.
What is surprise billing (sometimes called balance billing)?
- Surprise billing is when an out-of-network provider bills you for the difference between what your health insurance plan agrees to pay and the full amount charged for a service.
- Out-of-network means providers and facilities that have not signed a contract with your health insurance plan.
- Surprise billing can happen when you can’t control who is involved in your medical care. This could be when:
- You have an emergency.
- You schedule a visit at an in-network facility but are treated by an out-of-network provider without being told ahead of time.
- You are protected from surprise billing or balance billing in certain situations.
When am I protected from surprise billing?
The protections below are for patients that have HMO and PPO insurance in the state of Michigan. These do not apply to ground ambulance services, patients who consent to non-emergency services from out-of- network providers, or patients in self-funded health insurance plans.
Emergency Services (out-of-network facility)
If you get emergency services from an out-of-network provider or facility:
- You can’t be surprise billed for these emergency services. The provider or facility can only bill you for your health insurance plan’s in-network cost-sharing amount (like copay or coinsurance)
- You also can’t be surprise billed for services you get after you are in a stable condition unless you give written consent to be billed for these services.
Non-Emergency Services (out-of-network provider at an in-network facility)
If you get non-emergency services at an in-network facility from an out-of-network provider:
- The provider or facility can only bill you for your health insurance plan’s in-network cost-sharing amount (like copay or coinsurance) unless you give written consent and give up your protections.
- You can’t be surprise billed for these services if:
- You do not have the ability to choose an in-network provider, or
- You get services without being told the provider was out-of-network, or
- You receive care by an out-of-network provider at an in-network facility after you have had emergency services.
- You are never required to give up your protection from surprise billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your health insurance plan’s network.
- Other Services at an In-network Hospital or Outpatient Ambulatory Surgical Center (ASC). Certain doctors or health care providers may be out-of-network even though you are at an in-network hospital or outpatient ambulatory surgical center. In these cases, the most those providers may bill you is your health insurance plan’s in-network cost-sharing amount. This includes these services:
- Emergency Medicine
- Assistant Surgeon
- Hospitalist Services
- Intensivist Services
What other protections do I have when surprise billing is not allowed?
- You are only responsible to pay your share of the cost like copay, coinsurance, and deductibles that you would pay if the provider or facility was in-network. Your health insurance plan will pay out-of-network providers and facilities directly.
- Your health insurance plan generally must:
- Cover emergency services without approval before hand (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. That amount should be in your explanation of benefits
- Count any amount you pay for emergency services or out-of-network services toward your deductible or out-of-pocket limit.
Who should I contact if I have questions?
Contact your health insurance company or Henry Ford Customer Service and billing at (800) 999-5829. If your concern remains unresolved, you may file a complaint with the State of Michigan or call (877) 999-6442.
For more information about your rights under federal law, contact cms.gov/nosurprises at (800) 985-3059.