No Surprises Act

If you receive emergency care or are treated at an in-network hospital or outpatient surgical facility, federal and Washington state laws protect you from “surprise billing,” also called “balance billing.”

What is “surprise billing,” and when does it happen?

Under your health plan, you’re responsible for certain cost-sharing amounts. This includes copayments, coinsurance and deductibles. You may have additional costs or be responsible for the entire bill if you see a provider or go to a facility that is not in your plan’s provider network.

Some providers and facilities have not signed a contract with your insurer. They are called out-of-network providers or facilities. They can bill you the difference between what your insurer pays and the amount the provider or facility bills. This is called surprise billing.

Insurers are required to tell you, via their websites or on request, which providers, hospitals and facilities are in their networks. And hospitals, surgical facilities and providers must tell you which provider networks they participate in on their website or on request.

Emergency services

The most you can be billed for emergency services is your plan’s in-network cost-sharing amount, even if you receive services at an out-of-network hospital or from an out-of-network provider who works at the hospital. The provider and facility cannot surprise bill you for emergency services or some services you may receive after you’re in stable condition.

Certain services at an in-network hospital or outpatient surgical facility

When you receive surgery, anesthesia, pathology, radiology, laboratory or hospitalist services from an out-of-network provider while you are at an in-network hospital or outpatient surgical facility, the most you can be billed is your in-network cost-sharing amount. These providers cannot surprise bill you.

In situations when balance billing is not allowed, the following protections also apply:

• Your insurer will pay out-of-network providers and facilities directly. You are only responsible for paying your in-network cost-sharing.
• Your insurer must:
  • Base your cost-sharing responsibility on what it would pay an in-network provider or facility in your area and show that amount in your explanation of benefits.
  • Count any amount you pay for emergency services or certain out-of-network services (described above) toward your deductible and out-of-pocket limit.
• Your provider, hospital or facility must refund any amount you overpay within 30 business days.
• A provider, hospital or outpatient surgical facility cannot ask you to limit or give up these rights.

If you receive services from an out-of-network provider, hospital or facility in any other situation, you may still be surprise billed, or you may be responsible for the entire bill.

This law does not apply to all health plans. If your health insurance is through your employer, the law might not protect you. Be sure to check your plan documents or contact your insurer for more information.

Learn more about the No Surprises Act.

Filing a complaint

If you believe you’ve been wrongly billed, you may file a complaint with the federal government or call 800-985-3059; and/or file a complaint with the Washington State Office of the Insurance Commissioner or call 800-562-6900.