For Consumers

What consumers need to know about surprise or balance billing

State and federal law protects you from surprise or balance billing if you receive emergency care, including emergency behavioral health services at a medical facility or when you're treated at an in-network hospital or outpatient surgical facility by an out-of-network provider.

You’re 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 
  • Or from an agency certified to provide outpatient crisis services or medical withdrawal management services

What is surprise or balance billing?

Surprise billing happens because some types of medical providers and or facilities may not be contracted with your health insurer even though they provide services at a hospital or facility that is in your health plan’s provider network. You may also be taken to a hospital that is not in your health plan’s provider network in an emergency situation. 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 provider billed for their services. 

Recent state and federal laws prevent people from getting a surprise medical bill when they receive emergency care from a hospital or certain behavioral health treatment facilities or if they have a scheduled procedure an in-network facility and receive care from an out-of-network provider. In this case, if an insurer and provider cannot agree on a price for the covered services, they must go to arbitration and cannot bill the consumer for the disputed amount.

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. 

The state and federal laws apply to all health plans

Surprise billing protections apply to all state-regulated health plans, state and school employee benefit plans and self-funded group health 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? 

If you receive a surprise medical bill, you're not responsible for paying it. Your insurer must pay the out-of-network provider and facility directly. You are only responsible for your in-network cost-sharing, including any copays, coinsurance and deductible. 

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 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, 114.60KB) detailing your rights under the balance billing protection act and letting you know when you can and cannot be balanced 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.
  • For most health plans, providers and hospitals cannot ask you to limit or give up these rights.
  • Provide notice to you (PDF, 114.60 KB) detailing your rights under the balance billing protection act to let you know when you can and cannot be balanced billed. 

Know your rights under the Balance Billing Protection Act in other languages