When You Get Care

Part of being an informed health care consumer is using your plan’s network of providers to get care. But sometimes where you get care or who provides it is out of your control.

Consider the following situations:

You were balance billed for out-of-network emergency room care.
You see out-of-network charges on your invoice even though you received care at an in-network facility.
Your trusted doctor is leaving the network in the middle of your treatment and now you need to scramble to find a new doctor or else pay more.

These examples can wreak havoc to both your emotional and financial wellbeing. Thanks to the No Surprises Act, these surprise billing situations should no longer occur.

Emergency Services

Your protections in an emergency

When it’s an emergency, your health is what matters. What you’ll be charged for care isn’t top-of-mind.

New protections have been put in place so that you are better protected financially while undergoing emergency care.

Emergency services received in a hospital or independent freestanding emergency department must be covered as in-network, even if the provider or facility is out-of-network.

What will you be charged in an emergency?

Even if you are at an out-of-network facility, your cost-sharing will be the same as it would be at an in-network facility, and your cost-sharing payments will count toward any in-network deductible or out-of-pocket maximums.

You’re also protected from balance billing (also called surprise billing) by the out-of-network provider or facility. Surprise billing is the practice of billing you the difference between the provider’s actual charge (which is not negotiated with the plan) and the amount considered “allowable” under the plan. And this is in addition to any cost sharing (such as deductibles or co-pays) you might have.

What’s an emergency?

The treatment you receive must be for an emergency medical condition.

What it is: A condition with acute symptoms of sufficient severity (including severe pain) which if ignored could put you in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.
What it isn’t: A very mild condition such as a cold, ache or pain.

Some exceptions apply

Let's look at an example

Assume you go to an out-of-network emergency room with a life-threatening condition. That facility might normally charge $20,000 to someone without in-network coverage. However, under the new surprise medical billing protections, if the Qualifying Payment Amount (QPA) is $10,000 and your in-network coinsurance amount is 20%, you'll pay $2,000 (20% x $10,000). The hospital is prohibited from "surprise billing" you for any additional amount.

What is the Qualifying Payment Amount (QPA)?

The QPA is the median of an insurer's contracted rate for a particular service in a specific geographic region. Under the No Surprises Act, the QPA will be used to determine how much a patient must pay for protected out-of-network services.

Out-of-Network Charges

Your protections from hidden charges

Has this ever happened to you?

You did everything right by going to an in-network provider. But after you received care and received the bill, you see you were charged some services at an out-of-network rate because certain providers were not in the network.*

The No Surprises Act protects you from this surprise billing practice. The law states that out-of-network ancillary providers cannot charge the out-of-network rate when you are using an in-network facility. Air ambulances are also prohibited from surprise billing.

Ancillary services include:

Emergency-medicine related services, anesthesiology, pathology, radiology, and neonatology, regardless of whether provided by a physician or non-physician practitioner
Services provided by assistant surgeons, hospitalists, and intensivists
Diagnostic services (including radiology and laboratory services)
Services provided by an out-of-network provider if there is no participating provider who can furnish such item or service at such facility

Keep in mind that these types of services are not protected from surprise billing protections:

Non-emergency services provided at an out-of-network facility
Non-emergency services received from an out-of-network emergency room
Ground ambulance services

*If this hasn’t happened to you, that’s great. Your plan may already step in to protect you from these involuntary out-of-network charges and surprise billing practices. Many states prohibit or limit surprise billing in certain situations for insured plans.

Doctors Leaving Network

Continuity of care: Protection from doctors leaving the network

If you are receiving continuing care from an in-network provider and the provider’s in-network status changes, you may elect to receive transitional care from the provider at the in-network cost sharing amount for up to 90 days after the provider’s status changes. The provider must accept payment and cost-sharing at in-network rates. Your benefits will continue to be paid at the in-network level.

What’s continuing care?

A course of treatment for a serious and complex condition
A course of institutional or inpatient care
Non-elective surgery, including postoperative care
A course of treatment for pregnancy
Treatment for a terminal illness

What’s a serious and complex condition?

This means, in the case of an acute illness, a condition that is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm. In the case of a chronic illness or condition, a condition that is life-threatening, degenerative, potentially disabling, or congenital; and requires specialized medical care over a prolonged period of time.

Let's look at an example

Soraya is pregnant with her second child. She is 32 weeks along. She is seeing the same obstetrician that she used with her first baby. Her obstetrician lets her know she will no longer be considered a network provider at the end of the month.

Soraya is worried that she will now have to pay out-of-network cost sharing (and face possible balance billing) to continue seeing her doctor. But because of the No Surprises Act, her doctor must honor the in-network rates through the next 90 days.