GATEWAY ENT - NO SURPRISE ACT NOTICE
Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.
What is “balance billing” (sometimes called “surprise billing”)?
You’re 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 they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). 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.
Additionally, Missouri protects patients from surprise medical bills for health care services at an in-network facility from an out-of-network provider from the time the patient presents with an emergency medical condition until the patient is discharged.
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 can 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 types of 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 out-of-network care. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have these protections:
● You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
Generally, your health plan must:
● Cover emergency services without requiring you to get approval for services in advance (also known as “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 in-network deductible and out-of-pocket limit.
If you think you’ve been wrongly billed, you may contact:
● the U.S. Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (1-800-633-4227) or visit www.cms.gov/nosurprises for more information about your rights under federal law; or
● the Missouri Department of Insurance at 1-800-726-7390 or by visiting https://insurance.mo.gov/ for more information about your rights under state law.
