This information was provided by CMS.gov and NJ.gov

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.

You are protected on a federal level under the No Surprises Act, and at the New Jersey State level under the Out-of-network Consumer Protection, Transparency, Cost Containment, and Accountability Act.

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, like a copayment, coinsurance, or deductible. You may have additional 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” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays 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 plan’s deductible or 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. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

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

Under New Jersey law, if you have a medical emergency, you should not have to worry about whether the hospital or doctor is in your insurance network. Even if the emergency room, ambulance provider, or emergency doctor is out-of-network, you generally only have to pay your normal in-network costs, such as your copay, deductible, or coinsurance. Providers cannot “balance bill” patients for the difference between the provider’s charge and the insurer’s payment. However, protections may stop if:

• you are stable enough to safely transfer to an in-network facility

• you choose to stay at the out-of-network facility after your insurance company informs you that it is out-of-network and a transfer is required

In that situation, the additional care may be treated as voluntary out-of-network care, and you could become responsible for higher costs.

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.

Under New Jersey law, these protections usually apply when:

• you did not knowingly choose the out-of-network provider

• no in-network provider was available.

However, if you knowingly and voluntarily choose an out-of-network doctor when an in-network option was available, you may be responsible for higher out-of-network costs.

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.

Patients in New Jersey cannot sign away their protections against surprise medical bills under the law. Simply signing paperwork does not automatically make you responsible for the out-of-network bill if you did not truly have a meaningful choice of provider. Therefore, if:

• you are at an in-network hospital

• you are in an emergency situation

• you otherwise receive care you did not truly choose

the provider still cannot send you a balance bill — even if you signed a form, waiver, or consent document saying you understood the provider was out-of-network.

Your mental health counselor generally CAN charge out-of-network:

Most therapists and counselors in private practice are allowed to remain fully out-of-network and charge patients directly if the patient voluntarily chooses their services. The New Jersey Out-of-network Consumer Protection, Transparency, Cost Containment, and Accountability Act is mainly aimed at protecting patients from unexpected or involuntary out-of-network charges — especially in hospitals, emergency care, and in-network facilities. If the counselor is not in your insurance network, and you knowingly choose to see that out-of-network counselor in a normal office or telehealth setting, you may be responsible for:

• higher copays

• deductibles

• coinsurance

• the difference between what the counselor charges and what insurance pays (balance billing)

In this case, you do have the right to request a Good Faith Estimate of what your services may cost.

Your counselor generally CANNOT balance bill you if:

• you receive emergency mental health services

• you receive inadvertent out-of-network services at an in-network facility and did not knowingly choose the out-of-network provider

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, contact 1-800-985-3059 for federal assistance. You can also contact New Jersey’s Department of Banking and Insurance and Real Estate Commission at 1-800-446-7467 or file a complaint online.

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

Visit www.nj.gov for more information about your rights under New Jersey state laws.