Your Rights and Protections Against Surprise Medical Bills

Since January 1, 2022, the No Surprises Act has offered protections for patients against certain surprise medical bills, which are unexpected bills from non-network providers for amounts not covered by insurance, also referred to as “balance billing.” Prior to the No Surprises Act, patients faced these “surprise bills” most often when they were unable to choose (or simply were unaware of) whether their provider was in or out of network, such as when receiving medical care during an emergency.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—such as when you have an emergency or when you schedule treatment at an in‐network facility but are unexpectedly treated by an out‐of‐network provider. The No Surprises Act combats this practice by protecting patients from balance billing under certain scenarios. Read below to learn more about four critical protections you have today under this law.

1. You are protected from balance billing for certain emergency services.

If you have an emergency medical condition and get emergency services from a non-network provider or facility, the most that non-network provider or facility may bill you is the amount that they would have charged you if you were treated by a network provider. The provider or facility is not able to bill you for any amount in excess of the Health Plan’s payment for the services you receive. This protection also applies to certain post-stabilization services.

2. You are protected from balance billing for certain services at a network hospital or ambulatory surgical center.

When you receive services from a network hospital or ambulatory surgical center, certain providers in your care team might be non-network. For example, when undergoing surgery at a network hospital, though your surgeon and assistant surgeon may be network providers, it is possible that your anesthesiologist may not be. In these cases, your cost-sharing is the same as if you had seen an in-network provider, and the out-of-network provider cannot bill you for amounts in excess of the Health Plan’s payment for the service. This applies to non-network providers who provide emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services.

3. You are never required to give up your protections from balance billing although you have the right to do so.

You may choose to see a non-network provider at a network facility or to receive post-stabilization services after being seen by a non-network emergency provider/facility. However, you are never required to give up your protections.

Please note that participants are encouraged to use in-network providers at in-network facilities. However, if you choose to use a non-network provider, it is important to carefully review with your non-network provider or facility any notice or consent form to waive your rights to surprise billing protections. This form generally explains your balance billing protections but allows you the option to give up these protections and pay more for your non-network care if you wish to use a non-network provider. It may also detail what your estimated out-of-pocket cost may be.

If you consent to waive your rights, you will be responsible for:

• The applicable non-network co-insurance rate; and
• Any billed amount that exceeds the Health Plan’s Allowed Amount on Covered Expenses.

NOTE: If you do choose to sign a waiver, the consent forms that are signed should be included with your claim submission. Anthem normally will review this form to confirm its validity. All consent forms are reviewed by Anthem to confirm if it is valid to remove surprise pricing or not.

To learn more about your full rights and protections under the No Surprises Act, visit www.dgaplans.org/Surprise-Billing-Notice.