Your Rights and Protections Against Surprise Medical Bills
Beginning January 1, 2020, Washington State law protects you from surprise, or balance, billing.
Under your health plan, you’re responsible for certain cost-sharing amounts. This includes copayments, coinsurance, and deductibles. You may have other costs, or have to pay the entire bill, if you see a provider or visit a health care facility that is “out-of-network”. These are providers and facilities that have not signed a contract with your insurer and therefore they are not “in-network”. Out-of-network providers or facilities 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.” An unexpected balance bill from an out-of-network provider is also called “surprise billing”.
Insurers are required to tell you, via their websites or on request, which providers and facilities are in their networks. Healthcare facilities and providers must also tell you which provider network they participate in on their website or on request.
If you get insurance through your employer, a Health Insurance Marketplace®, or and individual health insurance plan you purchase directly from an insurance company, you are also protected from balance billing for:
- most 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.
- certain additional services (such as radiology or laboratory) furnished by out-of-network providers as part of a patient’s visit to an in-network facility.
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:
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.
The Federal No Surprises Act:
The federal government’s No Surprises Act that took effect January 1, 2022, supplements Washington State’s surprise billing law. In addition to providing protections from balance billing, it also provides protections if you are uninsured, or if you decide not to use your health insurance for a service.
If you are uninsured, or choose not to use your insurance for services:
Under these new rules, if you do not have insurance, or choose not to use it, you can get a good faith estimate of how much your care will cost before you receive it, provided it is scheduled at least 3 days in advance. Make sure your healthcare provider gives you a good faith estimate in writing at least 1 business day before you receive medical services. Your written estimate is typically found in your patient portal. If you receive your good faith estimate in person, or by mail, make sure to save a copy or picture of the estimate.
Good Faith Estimate and Dispute Resolution
The No Surprises Act also establishes an independent dispute resolution process for payment disputes between plan and providers and provides new dispute resolution opportunities for uninsured and self-pay individuals when they receive a medical bill that is substantially greater than the good faith estimate that you get from the provider. For services provided in 2022, you can dispute a medical bill if your final charges are at least $400 higher than your good faith estimate, and you file your dispute claim within 120 days of the date of your bill.
Where can I learn more?
Still have questions?
Visit CMS.gov - No Surprises Act, or call their Help Desk at 1-800-985-3059 for more information. TTY users can call 1-800-985-3059.
If you believe you’ve been wrongly billed:
file a complaint with the Washington State Office of the Insurance Commissioner at Washington State Office of the Insurance Commissioner or call 1-800-562-6900