No Surprise Act

Your Rights and Protections Against Surprise Medical Bills

When you get 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:

Emergency services:

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.

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.

The State of Missouri prohibits out-of-network providers from billing enrollees for any amount beyond in-network level of cost sharing. This protection applies to:

-HMO, PPO and EPO enrollees

-For emergency service provided by out-of-network professionals at in-network facilities

-Provided by all or most classes of health care professionals

The State of Missouri provides a dispute resolution process which may include negotiations or arbitration between your provider and your payer.

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.

When balance billing isn’t allowed, you 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.

See the below line items for your Good Faith Estimate for the cost of services:

    Office Visit 1 limited issue – $160 / visit

    Office Visit 2 issues or more addressed OR Full Skin Exam – $195 / visit

    Shave Biopsy – $175 / procedure

    Punch Biopsy – $195 / procedure

    Tissue Pathology Fee (at outside facility) – $175 / specimen or skin sample

    Cryotherapy Destruction – $110 per 5 lesions, in addition to the office visit fee

    ILK Intralesional Kenalog Injection (Steroid) – $75 / each 10mg injected, in addition to the office visit fee

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 provider 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’ve been wrongly billed, you may send potential violations of federal or state law to the U.S. Department of Heatlh & Human Services at 1-800-985-3059 or https://www.cms.gov/nosurprises/consumers or the Missouri Department of Commerce and Insurance at 573-751-4126 or https://insurance.mo.gov/consumers/complaints/index.php.