Your Rights and Protections Against Surprise Medical Bills

OMB Control Number: 0938-1401

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional 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” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays 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 plan’s deductible or 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. Surprise medical bills could cost thousands of dollars depending on the procedure or service. 

You are protected from balance billing for:

• Emergency Services

  • If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network 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.

  • Additionally, Georgia law protects you from surprise medical bills for: 1) covered emergency medical services provided by an out of network provider or at an out of network facility, and 2) covered non-emergency services from an out-of-network provider. This prohibition on balance billing does not apply if you chose to receive non-emergency services from an out-of-network provider and provided your oral and written consent.

• 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 are never required to give up your protection 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.

Additionally, Georgia law states that these protections require that you only pay your in-network cost-sharing amount. These protections apply to clients with coverage through a state healthcare plan, managed care plan, or a third party that opts into the prohibition from balance billing.

When balance billing isn’t allowed, you also have these protections: 

• You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly. 

• Generally, your health plan must: 

  • Cover emergency services without requiring you to get approval for services in advance (also known as “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 in-network deductible and out-of-pocket limit. 

If you think you’ve been wrongly billed, you may contact:

• The Centers for Medicare & Medicaid Services at 1-800-985-3059 or visit https://www.cms.gov/nosurprises for more information about your rights under federal law.

• The Georgia Office of Commissioner of Insurance and Safety Fire at 1-800-656-2298. Please visit the Georgia Secretary of State website for more information about your rights under state law.