Balance Billing Ohio: What the Law Means for You

Balance billing in Ohio can be a stressful experience, especially if you're not familiar with the laws surrounding it.

In Ohio, balance billing is prohibited for emergency services, which means that your insurance company and healthcare provider must work together to settle the bill.

You can't be charged more than the in-network cost-sharing amount for emergency services, even if the provider is out-of-network.

This protection applies to both in-network and out-of-network patients, ensuring that everyone receives fair treatment in emergency situations.

Ohio's Surprise Billing Law is designed to protect patients from surprise medical bills. The law became effective on January 12, 2022, and aims to prevent patients from receiving and paying surprise medical bills, especially those stemming from unanticipated out-of-network care.

Ohio residents who receive emergency care at an out-of-network facility or are treated by an out-of-network provider at an in-network hospital are protected from surprise billing. This protection applies to services from an out-of-network provider at an in-network facility, unless the patient has given prior written consent.

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The Ohio law limits cost-sharing amounts, such as coinsurance, copayments, and deductibles, to the patient's in-network amounts. However, the law also requires health plans to reimburse certain providers for emergency out-of-network care at the highest of three statutory rates unless independently negotiated.

Here are the types of services that are covered under the Ohio Surprise Billing Law:

Surprise billing, also known as balance billing, is an unexpected balance bill that can happen when you receive care from an out-of-network provider at an in-network facility.

You might receive a surprise bill if you can't control who is involved in your care, such as in an emergency or when you're treated by an out-of-network provider at an in-network hospital.

Surprise billing can be prevented in some cases. If you receive services from an out-of-network provider at an in-network facility, you can't be balance billed unless you have given your prior written consent.

Here are some key facts about surprise billing:

Ohio's Surprise Billing Law, R.C. § 3902.51, became effective January 12, 2022, but its impact on health plans is still evolving.

The law aims to prevent patients from receiving surprise medical bills, specifically those stemming from unanticipated out-of-network care.

Cost-sharing amounts, such as coinsurance, copayments, and deductibles, are limited to the patient's in-network amounts under the Ohio law.

However, the law also mandates that applicable health plans must reimburse certain providers for emergency out-of-network care at the highest of three statutory rates unless independently negotiated.

The Ohio law requires insurers to reimburse medical providers for unanticipated out-of-network care, emergency services, and clinical laboratory services.

Here are the specific situations where reimbursement is required:

The Ohio Department of Insurance (ODI) is charged with administering and enforcing the Ohio law, which applies to certain health plans, insurance companies, multiple employer welfare arrangements, non-federal governmental health plans, and other entities subject to the ODI's jurisdiction.

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If you're struggling to pay your medical bills, you're not alone. Cleveland Clinic offers financial assistance to those who need it.

You can find federal eligibility guidelines and learn how to request help on the Cleveland Clinic's financial assistance page. This page is a great resource to get you started.

Cleveland Clinic provides financial assistance to patients who are unable to pay their bills.

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You are protected from surprise medical bills in certain situations. If you receive emergency care at an out-of-network facility or are treated by an out-of-network provider at an in-network hospital, the laws protect you from surprise or balance billing.

You can't be balance billed unless you've given your prior written consent. This means that if you receive services from an out-of-network provider at an in-network facility, you can't be charged the difference between the in-network and out-of-network rates without your consent.

Ohio residents can contact the Ohio Department of Insurance at 800.686.1526 for more information about their rights under Ohio state laws. Florida residents can contact the Florida Office of Insurance Regulation at 850.413.3140 for more information about their rights under state laws.

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You're protected from balance billing for emergency medical conditions. 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.

Certain services at in-network hospitals or ambulatory surgical centers are also protected. If you receive services from an in-network hospital or ambulatory surgical center, providers like emergency medicine, anesthesiology, pathology, radiology, laboratory, neonatology, assistant surgeons, and hospitalists or intensivists can't balance bill you.

Here are some services that are protected from balance billing:

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.