No surprise billing

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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 healthcare 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 healthcare 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 innetwork

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-ofnetwork

provider or facility, the most the provider or facility may bill you is your plan’s innetwork

cost-sharing amount (such as copayments and coinsurance). You cannot 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.

The state of Georgia and the federal government both have laws to protect you from balance

billing, though they are different. State rules apply only to fully insured commercial health

insurance plans and some government plans. Federal rules may also apply to commercial

health insurance in situations where you received healthcare services in another state, your

health insurance is regulated by a state other than Georgia or the healthcare service you

received is not regulated by the state law. Most of the differences between the state and

federal laws are in the way the rules affect providers and health insurers, so you usually won’t

need to worry about that. However, the grievance processes are different, as indicated on the

government websites listed below.

Certain services at an in-network hospital, ambulatory surgical center or other facility

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 cannot balance bill you and may not ask you to give up your

protections not to be balance billed. Under Georgia law, this rule also applies to imaging

centers, birthing centers and similar facilities, in addition to hospitals and ambulatory surgical

centers. If you get other services at these in-network facilities, out-of-network providers cannot

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.

The best way to find an in-network provider is to use the online provider directory on your health

plan’s website.

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). Under Georgia law, your health plan cannot later deny such services because they don’t consider them medically necessary.
  • 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’ve been wrongly billed, first contact your provider and/or your health plan for an explanation. If they can’t resolve your concerns, you can contact the Georgia Office of the Commissioner of Insurance and Safety Fire online at https://oci.georgia.gov/ or by phone at 404-656-2070.

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

Visit https://oci.georgia.gov/how-do-i-file-complaint for more information about your rights under Georgia law.