Your Rights and Protections Against Surprise Medical Bills

¿Qué es la "facturación de saldo" (a veces llamada "facturación sorpresa")?

Cuando consulta a un médico o a otro profesional sanitario, puede tener que pagar determinados gastos de su bolsillo, como un copago, un coseguro y/o una franquicia. Es posible que tenga otros gastos o que tenga que pagar la factura completa si acude a un proveedor o a un centro sanitario que no pertenece a la red de su plan de salud.

“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.

La "facturación sorpresa" es una factura de saldo inesperada. Esto puede ocurrir cuando usted no puede controlar quién interviene en su atención, como cuando tiene una urgencia o cuando programa una visita en un centro de la red pero inesperadamente le atiende un proveedor fuera de la red.

You are protected from balance billing for:

Emergency services
If you have an emergency medical condition and get emergency services from an out-ofnetwork provider or facility, the most the provider or facility may bill you is your plan’s innetwork 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 give up your protections not to be balanced billed 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, 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.

Upon scheduling an appointment for nonemergency medical services, or at your request, your health care provider must disclose whether they participate in your health insurance plan (and must update you if this information changes during the course of your treatment). If your provider participates in your health insurance plan, the provider has to inform you of your right to request disclosure of the allowed amount and facility fee(s) (or an estimate of the maximum allowed amount and fees), and inform you how to obtain information regarding any applicable out-of-pocket costs. If your provider does not participate in your health insurance plan, the provider must provide the charge amount, any facility fees for your service, advise you of your potential financial liability for any non covered services, and inform you that you may be able to receive care at a lower cost from a provider that participates in your health insurance plan.

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 believe you’ve been wrongly billed, you may contact the Department of Health and Human Services at 1-877-696-6775 or the Massachusetts Department of Health at 617-624-6000.

Visit https://www.cms.gov/nosurprises/consumers for more information about your rights under federal law.

Visit https://malegislature.gov/Laws/GeneralLaws/PartI for more information about your rights under MA law.