Your Rights and Protections Against Surprise Medical Bills
When you receive emergency care or are treated by an out-of-network (OON)provider at an in-network hospital or surgery center, you are protected from surprise billing. You generally won’t owe more than your plan’s usual cost-sharing amount (like copays, coinsurance, or deductible).
What is “balance billing” (also called “surprise billing”)?
If you receive care from a provider who is not contracted with your health plan (out-of- network), they may charge you for the diCerence between their rate and what your plan pays –this is called balance billing. In many cases, this amount is significantly higher than what you’d pay in-network.
Balance billing is especially common in situations where you don’t choose the provider – such as anesthesia during a scheduled surgery or in emergencies where you can’t control who treats you.
You are protected from balance billing in certain situations:
Emergency Services
If you receive emergency care from an out-of-network provider or facility, they cannot charge you more than your in-network cost-sharing amount – even after your condition is stabilized. These protections apply under both federal and Arizona law. You cannot be asked to waive these protections unless you are stable and consent in writing.
Care at In-Network Hospitals or Surgery Center
When receiving treatment at an in-network facility, certain specialists involved in your care (like anesthesiologists, radiologists, or pathologists) may not be in-network. These providers cannot balance bill you and may not ask you to waive your rights.
Arizona law also requires written consent before you can agree to pay out-of-network rates for covered services.
If balance billing is not allowed, you are still responsible only for:
- The same cost-sharing you’d pay if the provider were in-network
- No additional charges from the provider
- Any payments you make must count toward your in-network deductible and out-of- pocket maximum
Your health plan must:
- Cover emergency services without requiring prior authorization
- Cover emergency services provided by out-of-network providers
- Base your cost-sharing on in-network amounts
- Count your payments toward your in-network deductible and out-of-pocket maximum
If you believe you’ve been wrongly billed, you can contact:
- No Surprises Help Desk (CMS): 1-800-985-3059
- Arizona Department of Insurance and Financial Institutions: 602-364-3100
- Or visit: www.cms.gov/nosurprises