When you get emergency care or get treated by a nonparticipating provider at a participating hospital or ambulatory surgical center, you are protected from balance or surprise billing. In these cases, you shouldn't be charged more than your plan's copayments, coinsurance or deductible.
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance or a deductible. You may have additional 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.
Nonparticipating describes providers and facilities that haven’t signed a contract with your health plan to provide services. Nonparticipating providers may be allowed to bill you for the difference between what your plan pays 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 plan's deductible or annual out-of-pocket limit.
Balance billing, sometimes called 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 schedule a visit at a participating facility but are unexpectedly treated by a nonparticipating provider.
If you have an emergency medical condition and get emergency services from a nonparticipating provider or facility, the most they can bill you is your plan’s in-network out-of-pocket amount, such as copays, coinsurance and deductibles. 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.
Depending on your plan, you may have additional protections under Michigan law if you receive post-stabilization services from a nonparticipating provider when you’re in a participating facility. If your plan is governed by Michigan law, those providers can’t balance bill you even if you give written consent.
When you get services from a participating hospital or ambulatory surgical center, certain providers there may be nonparticipating. In these cases, the most those providers may bill you is your plan’s in-network out-of-pocket 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 participating facilities, nonparticipating 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 from a nonparticipating provider. You can choose a provider or facility in your plan’s network.
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.
If you believe you’ve been incorrectly billed, contact the No Surprises Help Desk at 1-800-985-3059 or call the Michigan Department of Insurance and Financial Services at 1-833-275-3437.
Visit https://www.cms.gov/nosurprises for more information about your rights under federal law.
Visit https://michigan.gov/difs for more information about your rights under Michigan law.
