The “No Surprise Act” requires that we post the following notice to all of our patients on our website.

The “No Surprise Act” requires that we post the following notice to all of our patients on our website.

Your rights and protections against surprise medical bills.

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

 What is “balance billing” (sometimes called “surprise billing”)? 

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 or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

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

Under  Ohio  law,  cost  sharing  amounts,  which  include  coinsurance,  copayments  and deductibles, are limited to the patient’s in-network amounts in certain situations.

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.

Under Ohio law:

Patients are protected from balance billing when they receive emergency care at an out-of-network provider or at an out-of-network health care facility. Patients are also protected when they receive unanticipated out-of-network care at an in-network health care facility, but services are rendered by an out-of-network health care provider. Unanticipated out-of-network care means health care services, including clinical laboratory services, that are covered under a health benefit plan and that are provided by an out-of-network provider when either the patient does not have the ability to request the services from an in-network provider or the services are emergency services.

For all other services that are covered by a health benefit plan but are provided by an out-of- network provider at an in-network facility, the patients are protected from balance billing unless a) the provider informs the patient that the provider is not in-network, b) the provider gives the patient a good faith estimate of the cost of the services, and c) the patient consents to receive the services.

Health insurers regulated by the state are required to note on a covered patient’s insurance identification card the letters “ODI” if the patient’s health plan is subject to the state’s regulations on surprise billing.

When balance billing isn’t allowed, you also have the following protections: 

  • 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
    • 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’ve been wrongly billed —

you can contact the Ohio Department of Insurance through www.insurance.ohio.gov, consumer.complaint@insurance.ohio.gov, and 1-800-686-1526 to file a complaint. Visit https://insurance.ohio.gov/strategic-initiatives/surprise-billing for more information about your rights under Ohio law.

Visit  https://www.cms.gov/nosurprises/consumer-protections  for more information about your rights under federal law. If you believe you’ve been wrongly billed, you may contact the No Surprises Help Desk at 1-800-985-3059.