Balance billing, often referred to as surprise billing, occurs when you receive care from an out-of-network provider or facility. You may be billed for the difference between what your health plan covers and the total cost of the service. This amount is typically higher than in-network costs and may not count toward your annual out-of-pocket limit.

• Emergency Services: If you receive emergency care from an out-of-network provider or facility, you are only responsible for your plan’s in-network cost-sharing amounts. This protection extends to services provided after you are stabilized unless you consent to receive out-of-network care.

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• Certain Services at In-Network Facilities: At in-network hospitals or ambulatory surgical centers, some providers might be out-of-network. However, they can only bill you for your in-network cost-sharing amounts for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services.

In Arizona, additional laws protect patients from surprise medical bills for:

• Emergency services and related care provided by out-of-network providers at in-network facilities.

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• Non-emergency services provided by out-of-network providers at in-network facilities if proper disclosure is not given.

Patients with coverage through certain insurers are protected, and HMOs cannot charge more than the agreed amount.

When balance billing is prohibited, you are only responsible for in-network cost-sharing amounts. Your health plan must:

• Cover emergency services without requiring prior authorization.

• Cover out-of-network emergency services.

• Apply your payments toward your deductible and out-of-pocket limits.

If you believe you’ve been wrongly billed, you can contact:

• The U.S. Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE or visit CMS No Surprises.

• The Arizona Department of Insurance and Financial Institutions at 1 (602) 364-3100.

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Good Faith Estimate

You have the right to receive a Good Faith Estimate of the cost of your medical care if you are uninsured or not using insurance. This estimate should include all related costs and be provided in writing at least one business day before your service. If your final bill exceeds the estimate by $400 or more, you can dispute it. Keep a copy of your Good Faith Estimate for your records.

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For more information about your rights under federal and Arizona law, visit CMS No Surprises, AZ Department of Insurance & Financial Institutions, or call 1-800-MEDICARE.

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