Emergency Services and the Balance Billing Ban

Emergency services: must be covered without prior authorization, whether the provider participates or not; cost-sharing (coinsurance, copay, benefit limits) may hit a nonparticipating provider only if the exact requirement applies to participating providers. Balance billing — charging the insured the gap between what insurance paid and what the provider billed — is PROHIBITED for (1) nonemergency care at an in-network facility when the insured had no ability and opportunity to choose a participating provider there, and (2) emergency care at an in-network OR out-of-network facility. The insurer is solely liable to the nonparticipating provider; the insured owes only copayments, coinsurance, and deductibles, and the provider may not collect anything more.

In an emergency — or ambushed by an out-of-network doctor inside an in-network hospital — your bill stops at your normal cost-sharing. The surprise part is the insurer's problem.