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:

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 receive services at an in-network hospital or ambulatory surgical center, certain providers at the facility 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, and 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.

Maryland-specific balance billing protections:

If you are in a Health Maintenance Organization (HMO) governed by Maryland law, you may not be balance billed for services covered by your plan, including ground ambulance services. 

If you are in a PPO or EPO governed by Maryland law, hospital-based or on-call physicians paid directly by your PPO or EPO (assignment of benefits) may not balance bill you for services covered under your plan and can't ask you to waive your balance billing protections. 

If you use ground ambulance services operated by a local government provider who accepts an assignment of benefits from a plan governed by Maryland law, the provider may not balance bill you. 

When balance billing isn't allowed, you also have the following protections:

• You are only responsible for paying your share of the cost (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 in-network deductible and out-of-pocket limit.
    

When your health plan says the new protections don't apply, you have appeal rights:
If your health plan denies payment of all or part of your claim because the plan says the item or service isn't covered or that there are limitations on the coverage, or because the plan considers the item or service not medically necessary, experimental or investigational, you can appeal that denial.  Under the new law you can ask for an independent external review of whether your health plan's denial complies with the new surprise billing and cost-sharing protections. 

For example, if your health plan covers emergency care and you go to the emergency room and your plan denies payment for the services because it doesn't believe the items or care you received were “emergency services," you can dispute this decision using an appeal process to help determine whether your health plan needs to cover the services. 

If your health plan uses your out-of-network cost-sharing (copay, coinsurance, or deductible) when you think it should have used your in-network cost-sharing, you can appeal that decision. 

If you believe you've been wrongly billed or your health plan has improperly processed your claim, call or email us for more information, or file a complaint here: https://www.marylandattorneygeneral.gov/Pages/CPD/HEAU/compOLBillEquipDispute.aspx

Health Education and Advocacy Unit
Office of the Attorney General
200 St Paul Place, 16th Floor
Baltimore, Maryland 21202
Phone: (410) 528-1840 or toll-free 1 (877) 261-8807
En español: 410-230-1712
Fax: (410) 576-6571
heau@oag.state.md.us
Website: http://www.marylandattorneygeneral.gov/Pages/CPD/HEAU

If you believe your health plan processed your claim incorrectly, you may also contact the Maryland Insurance Administration: 

Maryland Insurance Administration
Life and Health Complaints Unit
200 St Paul Place, Suite 2700
Baltimore, Maryland 21202
Phone (410) 468-2000 or toll free 1-(800) 492-6116
Fax: (410)468-2260
Website: http://www.insurance.maryland.gov

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

The rules don't apply to people with coverage through programs like Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE because these programs have other protections against high medical bills.