Protections Against Surprise Medical Bills

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 and are seen at an out-of-network facility, or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider. These visits can be quite costly.

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, coinsurance, and deductible). 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 to give up your protections not to be balanced billed for these post-stabilization services.

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’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.

You are only responsible for paying your share of the cost (like the 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.

Your health plan generally must:

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

If you believe you have been wrongly billed, you should first contact the provider or facility that sent you the bill as well as your health plan for an explanation of the charges. 

If they cannot resolve your concerns, you can contact the United States Department of Health and Human Services regarding potential violations of your federal protections. You can also contact the State of Alaska Division of Insurance. See below for the contact information of these agencies.

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

SouthEast Alaska Regional Health Consortium

Email: financialcounselor@searhc.org
Phone: 907.463.6611

Alaska Division of Insurance

Email: consumerservices@alaska.gov
Phone: 907.269.7900 or 1.800.INSURAK

The U.S. Department of Health and Human Services

Mail: 200 Independence Avenue, S.W., Washington, D.C. 20201
Phone: 1.877.696.6775

Visit cms.gov/nosurprises for more information about your rights under federal law.