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. The regulatory body for insurance in the state of Missouri is the Missouri Department of Insurance: https://insurance.mo.gov/consumers/health/ managingcost.php. RSMO 376.690

CERTAIN SERVICES AT AN IN-NETWORK HOSPITAL OR AMBULATORY SURGICAL CENTER
When you get services from an in-network hospital or ambulatory surgical center, certain providers there 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, or 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.

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

  • You are only responsible for paying your share of the cost (like 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-ofnetwork providers.
    • Base what you owe the provider or facility (cost-sharing) on what it would pay an innetwork 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-ofpocket limit.
      If you have questions about your Somers Eye Center bill, the billing office can be reached at 816.842.2015.

The federal phone number for information and complaints is: 1.800.985.3059.
To file a complaint or dispute with the Division of Consumer Affairs: email consumeraffairs@insurance.mo.gov.
Visit https://www.cms.gov/nosurprises for more information about your rights under federal law.

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law, health care providers need to give patients who don’t have insurance and patients who choose not to use their insurance an estimate of the bill for medical items and services. This also includes patients receiving treatment in which their insurance will not cover those services.

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment.

Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service if your services are scheduled less than 3 days in advance. Estimates can be provided within 3 business days if scheduled 10 days in advance. Or within 1 business day upon request. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

A dispute must be filed with the U.S. Department of Health and Human Services (HHS) within 120 calendar days (~ 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises .

TO REQUEST A WRITTEN GOOD FAITH ESTIMATE FOR:
Somers Eye Center: Contact Biller at 816.842.2015 for selfpay services and/or services covered by insurance.