What is balance billing?
Balance billing occurs when an out-of-network provider bills an enrollee for charges other than copayments, coinsurance or the amount remaining on a deductible.
Out-of-network services are from doctors, hospitals and other health care professionals that have not contracted with your plan. A health care professional who is out of your plan network can set a higher cost for a service than professionals who are in your health plan network. Depending on the health care professional, the service could cost more or not be paid for at all by your plan. Charging this extra amount is called balance billing.
Consumer financial liability
In cases where you receive services from an out-of-network provider, you may be responsible for paying the difference between what your plan covers and what the provider charges. This means you could have financial liability for out-of-network services, especially if balance billing is permitted.
Exceptions to out-of-network liability
There are exceptions to out-of-network liability. For example, balance billing may be waived for emergency services received at an out-of-network facility. Additionally, the No Surprises Act provides protections against surprise medical bills for certain out-of-network services, including emergency care and some non-emergency services provided at in-network facilities.
Can you be balance billed?
Whether you can be balance billed depends on the type of service and the provider's network status. It is important to understand that you may be balance billed for services not covered by your plan or provided by out-of-network professionals.