Your Rights and Protections Against Surprise Medical Bills

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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.

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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 innetwork

facility but are unexpectedly treated by an out-of-network provider.

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You are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-ofnetwork

provider or facility, the most the provider or facility may bill you is your plan’s innetwork

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.

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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.

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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.

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Mississippi law prohibits balance billing. Under MS Code 83-9-5 (1) (i), if an out-of network

healthcare provider accepts a patient’s insurance assignment, the insurance company will pay

the provider directly for the patient’s treatment. That payment is considered payment in full to

the healthcare provider – this means the provider cannot bill the patient later for any amount

more than the payment received from the insurance company, other than normal deductible or

co-pays.

The Mississippi Insurance Department enforces the law to protect consumers against surprise

balance billing. If you receive a balance bill, make sure it is a balance bill (remember you owe

co-pays and deductibles). You may also call your insurance company to make sure it’s not a

mistake, and that the provider has accepted your Assignment of Benefits.

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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:

o            Cover emergency services without requiring you to get approval for services in

             advance (prior authorization).

o            Cover emergency services by out-of-network providers.

o            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.

o           Count any amount you pay for emergency services or out-of-network services

              toward your deductible and out-of-pocket limit.

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If you believe you’ve been wrongly billed, you may contact the Mississippi Insurance

Department at 1-800-562-2957 or CMS at 1-800-985-3059.

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Visit www.cms.gov/nosurprises/consumers for more information about your rights under

federal law.

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