Surprise Billing became law effective January 1, 2022, to protect consumers from “surprise” balance billing. Surprise Billing, commonly known as Balance Billing, occurs when an out-of-network provider bills a patient for their services beyond the amount paid by the patient’s healthcare insurance.
There are two situations in which the patient has limited control over whether an out-of-network provider administers care: Emergency and Non-emergent.
When there is an emergency, the patient goes to the nearest hospital emergency room that may or may not be in-network. Under the No Surprise Act, consumer protections extend to hospitalization immediately following emergency room care until the patient is transferred to an in-network facility or discharged.
Non-emergent facilities include hospitals, outpatient departments, critical access hospitals, and ambulatory surgical centers. For example, a patient might choose an in-network facility for planned surgery, not realizing that the radiologist, anesthesiologist, or assistant surgeon is not a participating network provider. Although rare, out-of-network care received at these facilities is not subject to the No Surprise Act.
For more information on the No Surprise Act, follow the link: What is the No Surprises Act?
Telemedicine is the remote delivery of healthcare services, such as health assessments or consultations, over the telecommunications infrastructure. It allows healthcare providers to evaluate, diagnose, and treat patients using standard technology, such as video-conferencing and smartphones, without needing an in-person visit.
In network is when a provider, physician, hospital, or other provider type, accepts your insurance. They are also frequently referred to as participating providers. Out of network is when the provider does not accept your insurance. If your provider is out of network, please contact Customer Service to nominate your provider.
Understanding deductibles, coinsurance and copays is important. A deductible is the portion you pay before your insurance pays. Coinsurance is your portion of the cost of a service and is generally a percentage of the amount allowed to be charged for services. It is paid after you’ve paid your plan deductible. A copay is the amount you are responsible for paying at the time the service is received.
Tiered copays vary by plan. Please contact customer service at 833-273-2253 for more information.
The out-of-pocket maximum is the maximum you could pay for covered medical services and/or prescriptions annually. This does not apply to monthly premiums, but typically to your deductible, coinsurance, and copays.
Your EOB shows you how your medical costs are distributed. It identifies a list of the services you received, costs, how expenses were divided between your provider and your copay but is NOT a bill.
The main component of the EOB provides specifics about the provider who performed the service, date, procedure type and costs.
Telehealth services vary by plan. Please contact customer service at 833-273-2253 for more information.
Please contact Customer Service at 833-273-2253 prior to travelling with specific questions.
