Your Rights and Protections Against Surprise Medical Bills
Members (participants, beneficiaries, or enrollees) are protected from surprise medical bills under both Michigan and federal law.
When you got 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:
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.
In Michigan, for emergency services covered by an insured plan, generally an out-of-network provider may not charge a Member more than the Member’s in-network coinsurance, copayment, or deductible for emergency services provided at either an in-network or out-of-network facility, so long as the Member’s health benefit plan covers the emergency services provided
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.
In Michigan, for emergency services covered by an insured plan, in general, an out-of-network provider may not charge a Member more than the Member’s in-network coinsurance, copayment, or deductible for non-emergency services provided at an in-network facility. This billing restriction for applies when the Member’s plan otherwise covers the non-emergency services provided to the Member, and either the Member doesn’t have the ability or opportunity to choose an in-network provider, or the Member was not provided with a proper disclosure of the provider’s out-of-network status prior to the services.
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-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provide 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-of-pocket limit.
If you believe you have been wrongly billed, you may contact the following agencies.
Michigan: You may file a complaint with the Michigan Department of Licensing and Regulatory Affairs online
Federal: File a complaint online. Phone number for information and complaints: 1-800-985-3059. Note, consumer and provider functionality for complaints inquiry and triage will not be operational until January 2022.