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:
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.
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.
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 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, you may contact the Department of Health and Human Services at 200 Independence Avenue, SW, Washington, DC 20201; or Phone #1-800-985-3059.
Visit https://www.cms.gov/nosurprises for more information about your rights under federal law.
NEW MEXICO RESIDENTS
If you are a covered person and you received a surprise bill from a nonparticipating (out-of-network) provider for health care services rendered in an amount that exceeds your cost-sharing obligation that would apply for the same health care services if the services had been provided by a participating (in-network) provider, you may have rights under the New Mexico Surprise Billing Protection Act (the "Act"). The Act generally prohibits health care providers from knowingly submitting a surprise bill for out-of-network services to an insured person that demands payment for any amount in excess of the cost-sharing amounts that would have been imposed by the insured person's health benefits plan if the health care service from which the surprise bill arises had been rendered by an in-network provider. The Act also provides that it is an unfair practice for a health care provider to knowingly submit a surprise bill to a collection agency.
Pursuant to the Act, please be advised of the following rights:
- Patients are responsible only for payment of applicable in-network cost-sharing amounts under the patient's health benefits plan.
- Patients should contact their insurance carriers in advance and/or the provider when possible, to determine if the scheduled health care services to be provided will be covered at an in-network rate.
- When prior contact is not possible for the care required, patients should contact their insurance carrier to discuss the surprise billing and to find the correct limitations that may apply.
- Patients may appeal a health insurer's determination regarding a surprise bill in accordance with the hearing procedures established by New Mexico's Patient Protection Act.
- The Surprise Billing Protection Act SB 337 can be obtained online at https://www.osi.state.nm.us.
- If additional information or questions arise, you may contact the New Mexico Superintendent of Insurance in Santa Fe, NM.
Office of Superintendent of Insurance
PO Box 1689
Santa Fe, NM 87504-1689