Medicare Balance Billing and Your Rights

Medicare balance billing can be a confusing and frustrating issue for many patients. You have the right to know what you're being charged for, and the law is on your side.

In 2020, the No Surprises Act was passed, which prohibits surprise medical billing, including balance billing, for emergency services. This means that you can't be charged more than your Medicare copayment or coinsurance for emergency services.

If you receive a balance bill, you can dispute it by contacting your Medicare plan and the provider. Your Medicare plan is required to help you resolve the issue.

Medicare has a process in place to resolve balance billing disputes, which includes a review of the bill and a decision by Medicare.

Surprise billing happens when a medical provider or facility isn't contracted with your health insurer, even if they're providing services at a hospital or facility in your plan's network.

You might receive a surprise bill for the difference between what your insurer agreed to pay and the amount the provider billed for their services, in addition to your expected out-of-pocket costs.

Recent state and federal laws prevent surprise medical bills for emergency care from in-network hospitals or certain behavioral health treatment facilities.

If you receive emergency care from an out-of-network provider at an in-network facility, the insurer and provider must go to arbitration and can't bill you for the disputed amount.

Surprise billing can be stressful, especially if you're already paying your deductible and coinsurance, only to receive a substantial additional bill.

As a Medicare beneficiary, it's essential to know what health insurers must do to protect you from surprise medical bills. Insurers must base your cost-sharing responsibility on what they would pay an in-network provider or facility in your area.

This means they need to show the amount on your Explanation of Benefits (EOB). If you receive emergency services or care from an out-of-network provider at an in-network facility, any amount you pay can count toward your deductible and out-of-pocket limit.

Here's a breakdown of what insurers must do:

By following these requirements, insurers can help you avoid surprise medical bills and ensure you receive the care you need without breaking the bank.

Medical providers and facilities have specific responsibilities when it comes to balance billing.

They must tell you which provider networks they participate in on their website or if you ask. This information is crucial in understanding your out-of-pocket costs.

To ensure transparency, providers must also provide notice to you detailing your rights under the Balance Billing Protection Act and letting you know when you can and cannot be balance billed.

Here are some key responsibilities of medical providers:

Medical providers and facilities have clear responsibilities when it comes to your care and billing.

They must tell you which provider networks they participate in on their website or if you ask. This information is crucial in understanding who is covered under your plan.

You have the right to be refunded any amount you overpay within 30 business days. This is a standard practice that ensures you're not unfairly charged.

For most health plans, providers and hospitals cannot ask you to limit or give up these rights. This means you're protected from being taken advantage of.

Here are the key responsibilities of medical providers in a concise list:

Balance billing typically happens when you get care from a healthcare provider or hospital that isn't part of your insurance company's network. This can lead to unexpected medical bills.

If your healthcare provider has opted out of Medicare entirely, you're responsible for paying the entire bill yourself. This is a crucial consideration for Medicare recipients.

You could be balance billed up to 15% more than Medicare's allowable charge if your healthcare provider doesn't accept assignment with Medicare. This means you'll have to pay the extra amount in addition to your regular deductible and/or coinsurance payment.

If you're facing a balance bill, it's essential to know your rights and the laws that protect you. About half of the 25 state laws on the books prohibit providers from issuing balance bills in most or all circumstances.

Some states offer comprehensive protection, covering emergency care, in-network non-emergency care, and prohibiting balance billing. Nine states, including California and New York, have such laws, which have proven effective in reducing surprise bills. For example, New York's law has curtailed out-of-network billing by 34 percent.

If you live in a state without comprehensive protection, you can still take action. You can call the doctor or medical facility to negotiate a lower bill, ask your insurance company to cover all or part of the out-of-network cost, or file a complaint with your state's insurance department or consumer protection office.

Here are some states with balance-billing laws:

In addition to state laws, Medicare and Medicaid also have provisions that protect you from balance billing. If you have Medicare and use a healthcare provider that accepts Medicare assignment, balance billing is prohibited. Similarly, if you have Medicaid and your healthcare provider has an agreement with Medicaid, balance billing is also prohibited.

If you have Medicare and your healthcare provider is a nonparticipating provider but hasn't entirely opted out of Medicare, you can be charged up to 15% more than the allowable Medicare amount for the service you receive.

Some states impose a lower limit, but in general, this 15% cap is known as the limiting charge and serves as a restriction on balance billing in some cases.

If your healthcare provider has opted out of Medicare entirely, they cannot bill Medicare at all and you'll be responsible for the full cost of your visit.

The limiting charge only applies to certain services and doesn't apply to supplies or equipment, and it's only relevant to non-participating providers who haven't signed an agreement to accept assignment for all Medicare-covered services.

Medicare defines a limiting charge as the highest amount of money you can be charged for a covered service by doctors and other healthcare suppliers who don’t accept assignments.

Choosing an out-of-network provider can lead to unexpected bills, even if your health insurance plan covers some out-of-network costs. This is because the provider isn't obligated to accept your insurer's payment as payment in full.

Some health plans, like HMOs and EPOs, don't cover non-emergency out-of-network services at all. This means you'll be responsible for the entire bill if you choose to go outside the plan's network.

If you obtain services that aren't covered by your health insurance policy, you'll be responsible for the entire bill. Your insurer won't require the medical provider to write off any portion of the bill.

Prior to 2022, people were commonly balance billed in emergencies or by out-of-network providers that worked at in-network hospitals.

Illegal billing practices are a thing of the past in the United States. This is due to agreements between healthcare providers and government programs like Medicare and Medicaid, as well as private insurance companies.

These agreements prohibit balance billing in certain situations. For example, when a hospital signs up with Medicare to see Medicare patients, it must agree to accept the Medicare negotiated rate as payment in full.

This is called accepting Medicare assignment. It's a requirement that ensures patients are not charged more than the agreed-upon rate.

Here are some specific situations where balance billing is prohibited:

The No Surprises Act, which took effect in 2022, also protects patients from surprise balance billing in emergency situations.

If you're worried about surprise medical bills, it's good to know that some states have laws in place to protect consumers. About half of the 25 state laws on the books prohibit providers from issuing balance bills in most or all circumstances.

Nine states have comprehensive protection: California, Connecticut, Florida, Illinois, Maryland, New Hampshire, New Jersey, New York, and Oregon. These states cover all emergency care and in-network non-emergency care, apply to all types of insurance, and prohibit balance billing.

Some states have proven effective at reducing surprise bills. For example, New York's law, enacted in 2014, has curtailed out-of-network billing by 34 percent.

Sixteen states offer lesser protections, including Arizona, Colorado, Delaware, Indiana, Iowa, Maine, Massachusetts, Minnesota, Mississippi, New Mexico, North Carolina, Pennsylvania, Rhode Island, Texas, Vermont, and West Virginia. These states may limit balance-billing prohibitions to emergency room treatment or not cover preferred provider organizations (PPOs).

Here's a breakdown of the states with comprehensive protection and lesser protections: