When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as 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 isn’t in your health plan’s network.
“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.
“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.
Certain services at an in-network hospital or ambulatory surgical center
If you get other services at an in-network hospital or ambulatory surgical center, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You may ask for an estimate of the amount that you will be charged for a nonemergency medical service provided by a health care facility or practitioner. If you are uninsured or intending to pay for the service out-of-pocket, federal law requires that a provider or facility provide you with an estimate for all scheduled nonemergency health care services at least 1 business day before the services are to be performed.
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.
If you believe you’ve been wrongly billed, you may contact the Ohio Department of Insurance at www.insurance.ohio.gov/wps/portal/odi/consumers or 1-614-644-2658.
Visit www.cms.gov/nosurprises or call 1-800-985-3059 for more information about your rights under federal law.