Billing

Your Rights and Protections Against Surprise Medical Bills

For services provided on or after January 1, 2022

When you receive emergency care or are 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 visit a doctor or another healthcare provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. However, you may incur additional costs or even the entire bill if you see a provider or visit a healthcare facility that is not within your health plan’s network.

“Out-of-network” refers to providers and facilities that do not have a contract with your health plan. These providers may bill you for the difference between what your health plan pays and the full amount charged for a service, a practice known as “balance billing.” This amount is often higher than the in-network costs for the same service and might not count towards your plan’s deductible or annual out-of-pocket limit.

“Surprise Billing” occurs when you receive an unexpected balance bill. This can happen when you cannot control who is involved in your care, such as during an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You’re protected from balance billing for:

Emergency services

If you have an emergency medical condition and receive emergency services at a hospital emergency department or freestanding emergency department, the most an out-of-network provider or facility may bill you for these emergency services is your plan’s in-network cost-sharing amount (such as copayments and coinsurance).

You cannot be balance billed for these emergency services. This includes services you may receive after you are in stable condition, unless you give written consent and waive your protections against balance billing for these post-stabilization services.

In addition to the federal No Surprises Act protections, the state where you receive services may have additional protections that apply to your visit.

Certain services at an in-network hospital or ambulatory surgical center

If you receive emergency medicine, anesthesia, pathology, radiology, laboratory, assistant surgeon, or hospitalist services by Apple ABA out-of-network providers while at an in-network hospital or ambulatory surgical center, the most you can be billed is your plan’s in-network cost-sharing amount.

These providers cannot balance bill you or ask you to waive your protections. If you receive other types of services at these in-network facilities, out-of-network providers cannot balance bill you unless you give written consent and waive your protections.

You are never required to waive protections against balance billing. You also are not required to receive out-of-network care. You can choose a provider or facility within your plan’s network.

Some states may have additional protections that apply to non-emergency services at an in-network facility, including: AZ, FL, GA, IN, MD, MA, MI, MN, MO, NM, NE, NJ, OK, RI, TN, VA.

You may not be balance billed above your plan’s in-network cost-sharing amount for: inadvertent out-of-network services (services covered under your health plan provided by out-of-network providers in an in-network facility when in-network services are unavailable or not made available to you, including laboratory testing); and out-of-network services provided on an emergency or urgent basis.

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

• You are only responsible for paying your share of the cost (such as copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.

• Generally, your health plan must:

  • Cover emergency services without requiring prior approval (also known as “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 towards your in-network deductible and out-of-pocket limit.

If you believe you have been wrongly billed by an Apple ABA Center or provider, please contact us at 201-270-0222.

Alternatively, you may contact CMS at 1-800-985-3059 or visit http://www.cms.gov/nosurprises/consumers for information about your rights under federal law. You may also contact your applicable state agency.