Your Rights and Protections Against Surprise Medical Bills

 

When you receive treatment by an out-of-network provider at an in-network medical facility, like MCHC, you are protected from surprise billing or balance billing.

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What is "Balance Billing" or "Surprise Billing"?

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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 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 is not in your health plan's network.

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"Out-of-network" describes providers and facilities which have not 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 towards your annual out-of-pocket limit.

 

"Surprise billing" is an unexpected balance bill. This can happen when you cannot 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.

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     When Balance billing is not allowed, you also have the following protections:

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You are only responsible for paying your share of the cost (like copayments, coinsurance and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.

 

If you get other services in-network, out-of-network providers cannot balance bill you, unless you give written consent and give up your protections.

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YOU ARE NOT REQUIRED TO GIVE UP YOUR PROTECTIONS FROM BALANCE BILLING. YOU ALSO ARE NOT REQUIRED TO GET CARE OUT-OF-NETWORK. YOU CAN CHOOSE A PROVIDER OR FACILITY IN YOUR PLAN'S NETWORK.

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Your health plan generally must:

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    Cover emergency services without requiring you to get approval for services in advance (prior authorization).

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    Cover emergency services by out-of-network providers.​

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    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 deductible and out-of-pocket limit.

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IF YOU BELIEVE THAT YOU HAVE BEEN WRONGLY BILLED, you may contact the U.S. Department of Health and Human Services (HHS) or the Kentucky Cabinet for Health and Family Services.

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