What is surprise or balance billing?

Surprise or balance billing happens because some types of medical providers and or facilities may not be contracted with your health insurer and are considered out-of-network. You may also be taken by an ambulance to a hospital that is not in your health plan’s network in an emergency, or if you schedule a surgery at an in-network facility but are treated by an out-of-network provider. So, in addition to your expected out-of-pocket costs, you might also get a bill for the difference between what your insurer has agreed to pay that provider and the amount the out-of-network provider billed for their services. 

You are protected from surprise or balance billing  

You are protected from surprise or balance billing when you receive emergency care, emergency behavioral health services, scheduled procedures at certain in-network facilities, such as hospitals, behavioral health emergency rooms, or surgical centers, and covered ground ambulance services. 

You are also protected if you receive emergency behavioral health services from a:

  • Mobile rapid response crisis team
  • Crisis triage or stabilization facility
  • Evaluation and treatment facility
  • An agency that provides outpatient crisis services or medical withdrawal management services

Balance billing protections apply to all state-regulated health plans and state and school employee benefit plans. Some self-funded group health plans provide greater protections to their members under our state law. These plans have notified us that they want to offer these additional protections to their enrollees.  

See a current list of self-funded group health plans that have selected to follow the state surprise billing law.

How much do you pay? 

For services protected from surprise or balance billing, the most the providers and facilities may bill you is your plan’s in-network cost-sharing amount. This includes copays, coinsurance, and deductibles. Your insurer must pay the out-of-network provider, facility, and ground ambulance provider directly. If you receive a balance bill, you are not responsible for paying it. 

What to do if you get a surprise bill

If you get a surprise bill, contact the provider or facility and tell them you believe you've been wrongly billed. You can also file a complaint with our office, and we will investigate on your behalf.

What health insurers must do

  • Base your cost-sharing responsibility on what it would pay an in-network provider or in-network facility in your area and show the amount on your Explanation of Benefits (EOB). 
  • Count any amount you pay for emergency services or services provided by an out-of-network provider at an in-network facility toward your deductible and out-of-pocket limit.
  • Tell you, via their websites or if you ask, which providers, hospitals, and facilities are in their networks.
  • Provide notice to you (PDF 205.78KB) detailing your rights under the Balance Billing Protection Act and letting you know when you can and cannot be balance billed. 

What medical providers and facilities must do

  • Tell you which provider networks they participate in on their website or if you ask.
  • Refund any amount you overpay within 30 business days.
  • Provide notice to you (PDF 205.78KB) detailing your rights under the Balance Billing Protection Act and letting you know when you can and cannot be balanced billed. 
  • For most health plans, providers and facilities cannot ask you to limit or give up these rights.

If you have coverage through a self-funded group health plan that doesn’t provide our state’s protections, in some limited situations, a provider can ask you to consent to waive your balance billing protections, but you are never required to give your consent. Please contact your employer or health plan for more information.

Know your rights under the law in other languages

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