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 “surprise billing” or “balance billing”)? When you see a health care provider, you may owe certain out-of-pocket costs, such as a copay, coinsurance, and/or deductible. You may owe the entire bill if you see a provider or visit a facility that is not 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 agrees to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more money than in-network costs for the same service and might not count toward your annual out-of-pocket limit. 

“Surprise billing” is an unexpected bill. This may happen when you cannot select 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.

The most an out-of-network provider 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 seek your consent to be balance billed. 

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. An out-of-network provider must give notice at least 5 business days before the services are scheduled to be provided, and include a notice summarizing your balance billing rights, including a good faith estimate of the charges for such services. The provider is obligated to explain any charges that exceed the good faith estimate. You are 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 (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 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 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 Indiana Department of Insurance by calling (317) 232-8582 or visit their website (https://www.in.gov./idoi) for more information about Indiana’s balancing billing laws.  Visit https://www.cms.gov/nosurprises/consumers for more information about your rights under federal law.