Your Rights and Protections Against Surprise Medical Bills

 

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.

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.

Many states have specific state laws to determine payments from insurers. Click here to view a list of state-specific information.

If no state law applies or if you think you’ve been wrongly billed, contact the federal regulators responsible for enforcing the federal surprise billing protection laws at 1‑800‑985‑3059.

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

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Transparency in Coverage (TIC) Machine Readable Files (MRFs)

The federal Transparency in Coverage Rule requires our group health plan to disclose price and cost-sharing information to participants. To comply, Envision has posted links to the Anthem and Surgery Plus webpages which provides access to pricing information via Machine-Readable Files.

A machine readable file is a digital representation of data or information in a file that can be imported or read by a computer system for further processing without human intervention.

Click here for the Aetna: Transparency in Coverage (TIC) machine readable files (MRFs)

This link leads to the Aetna machine readable files for Envision that are made available in response to the federal Transparency in Coverage Rule. The machine-readable files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.

Click here for the Anthem: Transparency in Coverage (TIC) machine readable files (MRFs)

These files follow the Centers for Medicare & Medicaid Services (CMS) defined layout and are in the CMS approved format (JSON). The files are published on anthem.com and will be updated on the first day of each month.

This link above, will allow you to search for Envision’s files on the Anthem site using our Employer Identification Number (EIN), 621493316.

When using the search option, the page will display links to several files, including:

• Applicable In-Network Negotiated Rate Files
• Out-of-Network Allowed Amount Files
• Out-of-Area Rates (applicable when members use providers in non-Anthem states.)

Click here for the AmeriBen: Transparency in Coverage (TIC) machine readable files (MRFs)

This link leads to the AmeriBen machine readable files for Envision that are made available in response to the federal Transparency in Coverage Rule. The machine-readable files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.

Click here for the Surgery Plus: Transparency in Coverage (TIC) machine readable files (MRFs)

This link leads to the Surgery Plus machine readable files for Envision that are made available in response to the federal Transparency in Coverage Rule. The machine-readable files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.

Click here for the HMSA: Transparency in Coverage (TIC) machine readable files (MRFs)

This link leads to the HMSA machine readable files for Envision that are made available in response to the federal Transparency in Coverage Rule. The machine-readable files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.