Navigating healthcare costs can be complex, especially when unexpected bills arise. Patients and visitors should be aware of their rights and protections against surprise billing, which can lead to significant financial burdens. Understanding these protections helps ensure you are not unfairly charged for services in situations beyond your control, particularly during emergencies or when receiving care at in-network facilities.
Your Rights and Protections Against Surprise Medical Bills
When you seek emergency treatment or are cared for by out-of-network providers at an in-network hospital or outpatient surgical center, federal and state laws shield you from balance billing. This means that, in these circumstances, your financial responsibility is limited to your plan’s copayments, coinsurance, and deductible amounts. You should not be billed for amounts exceeding what your insurance plan covers for these urgent services.
What Is Balance Billing and Surprise Billing?
Balance billing occurs when a healthcare provider bills you for the difference between what your insurance pays and the total charge for a service. This often happens if you visit a provider or facility that has not signed an agreement with your insurance plan, known as being “out-of-network.” Providers may attempt to charge you the full amount for the service, which surpasses the amount your plan considers covered — a practice known as balance billing. These excess charges can be substantial, frequently exceeding what you would pay if the provider were in-network, and they often do not count toward your deductible or out-of-pocket maximum.
Surprise billing is a specific form of balance billing that occurs unexpectedly, often when you have no control over who is involved in your care. For example, during an emergency or when receiving scheduled care at an in-network facility, you might be treated by an out-of-network provider without your knowledge. The resulting bills can be very high, sometimes running into thousands of dollars, depending on the services provided.
Protections Against Balance Billing
Emergency Services
If you experience a medical emergency and receive services from an out-of-network provider or facility, federal law limits your liability to your plan’s in-network cost-sharing amount—such as copayments, coinsurance, and deductibles. You cannot be billed for any additional amounts beyond these costs. This protection also applies to post-stabilization services, provided you give written consent to waive your protections.
State laws, including those in Florida, further strengthen these protections. If your insurance provider is based in Florida, you are generally protected from balance bills for emergency care, with your financial responsibility limited to your standard copayments, deductibles, and coinsurance.
Certain Services at In-Network Hospitals or Surgical Centers
When you receive care at an in-network hospital or outpatient surgical center, some providers—such as anesthesiologists, radiologists, or laboratory technicians—may be out-of-network. However, these out-of-network providers are only permitted to bill you up to your plan’s in-network cost-sharing amount. They are prohibited from balance billing you unless you provide written consent to waive these protections.
You are never required to give up your right to be protected from balance billing. Additionally, you can choose providers and facilities within your insurance network to avoid unexpected charges altogether.
Florida law also prohibits providers from balance billing for services covered by your insurance during non-emergency visits if you are enrolled in a Florida-based Health Maintenance Organization (HMO). Similarly, if you have a Preferred Provider Organization (PPO), protections are in place to prevent balance bills when you did not select an out-of-network provider.
Additional Protections When Balance Billing Is Not Allowed
- Your financial responsibility is limited to your usual cost-sharing amounts, such as copayments, coinsurance, and deductibles.
- Your health plan will pay out-of-network providers directly for any covered costs beyond your share.
- Emergency services are covered without prior approval or authorization.
- The amount you owe for emergency or out-of-network care is based on what an in-network provider would bill, as reflected in your explanation of benefits.
- Payments made for emergency or out-of-network services count toward your deductible and out-of-pocket limits.
Your Right to a Good Faith Estimate
Understanding Expected Healthcare Costs
Healthcare providers are required to provide patients who are uninsured or not using insurance with an estimate of the total costs of upcoming services. This Good Faith Estimate must include charges for tests, procedures, medications, and other related expenses.
- If you request an estimate or schedule a service at least three business days in advance, providers should give you a written estimate within one business day.
- For appointments scheduled 10 or more business days ahead, a written estimate must be provided within three days.
- You can request an estimate before scheduling any service, and providers are expected to furnish this information promptly.
- If you receive a bill that exceeds your estimate by $400 or more, you have the right to dispute it.
Keep copies of your estimates and bills for reference. If you believe you’ve been billed incorrectly, contact the No Surprises Help Desk at (800) 985-3059 or email FederalPPDRQuestions@cms.hhs.gov for assistance.
For more detailed guidance on your billing rights, visit CMS consumer resources.
Note that protections provided by federal law do not extend to insurance plans from other states or employer-sponsored plans outside of Florida.
—
Explore how emerging technologies like virtual and augmented reality are transforming medical care with VR and AR in healthcare, which is helping reduce surprises in patient billing and improve care delivery. Additionally, advancements in medical visualization tools, such as those discussed in from molecules to market, are streamlining the development and delivery of treatments, further enhancing patient safety and transparency.
Remaining informed about your rights ensures you can confidently navigate healthcare costs and avoid unexpected financial burdens.