Medical Bills

The short version

This lesson explains your rights when it comes to unexpected medical bills, often called 'surprise bills.' It focuses on protections provided by federal law, specifically the No Surprises Act. Understanding these rules can help you avoid paying more than you should for medical care and negotiate bills effectively.

The law this is built on

Every point below comes from the authority named next to it. Verify the current text before relying on it.

45 C.F.R. § 149.410(a)(1)
This section states that if you are enrolled in a group health plan or individual health insurance coverage, you generally cannot be billed for out-of-network emergency services for more than your plan's in-network cost-sharing amount.
Why it matters: This means you are protected from surprise bills for emergency care, even if the facility or provider is not in your insurance network.
45 C.F.R. § 149.410(b)(1)
This rule extends protections to certain non-emergency services provided at in-network facilities. If you receive care from an out-of-network provider (like an anesthesiologist) at an in-network hospital, you generally can't be surprise billed.
Why it matters: This prevents you from getting surprise bills when you choose an in-network facility but unknowingly receive care from an out-of-network doctor there.
45 C.F.R. § 149.410(c)
For non-emergency services where surprise billing is normally prevented, a provider can still bill you if they give you specific notice and get your written consent to be billed out-of-network.
Why it matters: This is a key exception: if you agree in advance and in writing, you can lose some No Surprises Act protections for those specific services.
45 C.F.R. § 149.410(e)
This section states that your health plan must cover emergency services without needing prior approval, and without considering whether the provider is in-network.
Why it matters: This ensures that your insurance will pay for necessary emergency care, and you won't be denied coverage because you went to an out-of-network emergency room.

Words you need to know

Surprise Bill: A bill you get for medical services that you didn't expect, often because an out-of-network provider treated you at an in-network facility or for emergency care.
No Surprises Act: A federal law that protects you from surprise medical bills in most emergency situations and for certain non-emergency services at in-network facilities.
Out-of-Network: A healthcare provider or facility that does not have a contract with your health insurance plan. Services from these providers often cost more.
In-Network: A healthcare provider or facility that has a contract with your health insurance plan to provide services at agreed-upon rates.
Cost-Sharing: The amount you are responsible for paying for healthcare services, such as deductibles, co-payments, and co-insurance. This is in addition to the premiums you pay.
Open Negotiation Period: A 30-business-day period where your health plan and the out-of-network provider try to agree on a payment amount for a surprise bill after you've paid your in-network cost-sharing.

Your rights

✓You generally cannot be balance billed for out-of-network emergency services beyond your health plan's in-network cost-sharing amount. (45 C.F.R. § 149.410(a)(1))
✓You generally cannot be balance billed for certain non-emergency services (like anesthesia or radiology) provided by an out-of-network provider at an in-network facility. (45 C.F.R. § 149.410(b)(1))
✓Your health plan must count any amount you pay for surprise bills towards your in-network deductible and out-of-pocket maximum. (45 C.F.R. § 149.410(a)(1)(iv))
✓You have the right to receive a 'Good Faith Estimate' of expected charges if you are uninsured or choose not to use your insurance. (45 C.F.R. § 149.610)
✓You have the right to receive information about your surprise billing protections from your health plan and healthcare facility. (45 C.F.R. § 149.430)

How the process actually works

1
Receive Bill
After medical services are provided.
You receive a medical bill from a healthcare provider or facility. Check if it's from an out-of-network provider for emergency care or for specific services at an in-network facility.
2
Review Bill for Surprise Billing
As soon as you receive the bill and EOB.
Compare the bill to your Explanation of Benefits (EOB) from your insurance. Look for charges higher than your in-network cost-sharing for emergency services or facility-based out-of-network providers. Check if you signed a 'surprise billing consent' form.
3
Contact Provider/Plan
Promptly after identifying a potential surprise bill.
If you suspect a surprise bill, contact both the provider who billed you and your health insurance plan. Explain why you believe the bill violates the No Surprises Act. Your plan should have already applied the No Surprises Act protections.
4
Dispute the Bill (If Needed)
After talking with your plan and provider, if the issue is not resolved.
If your plan doesn't apply the protections, you can dispute the health plan's decision. You can also file a complaint with the federal government or your state's insurance department if a provider or facility is trying to surprise bill you.
5
Pay In-Network Cost-Sharing
After your health plan has reprocessed the claim and notified you of your correct cost-sharing.
Once the No Surprises Act protections are applied, you are only responsible for your health plan's in-network cost-sharing amount for the protected services. You should pay no more than this amount.

Deadlines that can end your case

Federal Complaint Filing
Varies; generally as soon as possible after receiving a surprise bill.
Timely filing can help ensure your complaint is addressed while the bill is still active.
Health Plan Internal Appeals
Usually 180 days from receipt of an adverse benefit determination.
Missing this deadline might prevent you from appealing your health plan's decision about the bill.
State Complaint Filing
Varies by state.
Check your state's Department of Insurance website for specific timelines; missing them may limit your options.

Costly mistakes

✕Paying a surprise bill before confirming it's correct under the No Surprises Act.
✕Not checking your Explanation of Benefits (EOB) to see how your insurance processed the claim.
✕Signing a 'surprise billing consent' form without fully understanding what you're agreeing to.
✕Not contacting your health insurance plan when you receive a bill you think is a surprise bill.
✕Ignoring a surprise bill, which could lead to collections or damage your credit.
✕Waiting too long to dispute a bill, which can make it harder to resolve.

Your checklist

Identify if your bill is for emergency services or for services from an out-of-network provider at an in-network facility.
Review your Explanation of Benefits (EOB) from your insurance company to see how they processed the claim.
Check if you signed a notice and consent form for out-of-network billing for the specific service.
Contact your health plan to ask if the No Surprises Act applies to your bill and confirm your maximum cost-sharing.
Contact the provider's billing department to dispute charges that exceed your No Surprises Act protections.
If not resolved, file a complaint with the federal government (HHS) or your state's Department of Insurance.
Pay only the amount you owe, which is generally your in-network cost-sharing, once protections are applied.

Common questions

What is a 'surprise bill'?

A surprise bill is an unexpected medical bill you receive, often because an out-of-network provider treated you at an in-network hospital or for emergency care. The No Surprises Act protects you from many of these bills. (45 C.F.R. § 149.410)

Does the No Surprises Act apply to all medical bills?

No, it mainly applies to emergency services and certain non-emergency services provided by out-of-network providers at in-network facilities. It does not apply to ground ambulance services, or if you knowingly and willingly agree to be billed out-of-network for specific services after receiving proper notice. (45 C.F.R. § 149.410(a), (b), (c))

What if my provider asks me to sign a form agreeing to out-of-network charges?

This form is called a 'notice and consent' form. If you sign it, you may lose your No Surprises Act protections for those specific services and agree to pay more. Do not sign it if you do not understand it or do not wish to be billed out-of-network. (45 C.F.R. § 149.410(c))

Who do I contact if I think I received a surprise bill?

First, contact your health insurance company to understand how they processed the claim and if No Surprises Act protections were applied. You can also contact the federal No Surprises Help Desk for assistance or file a complaint with the Department of Health and Human Services (HHS) or your state's insurance department.

What is my maximum financial responsibility under the No Surprises Act?

If the No Surprises Act applies, your maximum responsibility for the protected services is your plan's in-network deductible, co-payment, or co-insurance amounts. Your health plan must count these amounts towards your in-network out-of-pocket maximum. (45 C.F.R. § 149.410(a)(1)(iv))

How this changes by state

While the No Surprises Act is a federal law, some states have their own laws that offer similar or even stronger protections against surprise medical bills. If your state has a law that provides more protection than the federal law, the state law usually applies. You can find your state's specific rules and complaint processes by visiting your state's Department of Insurance or Attorney General's office website.

When you need a lawyer

You might consider speaking with a lawyer if your health insurance plan or a provider refuses to follow the No Surprises Act, if you've been sent to collections for a bill you believe is illegal, or if you signed a 'notice and consent' form but believe you were pressured or did not fully understand it. A lawyer specializing in healthcare or consumer law can help you understand your options.

Do this today

→Review your recent medical bills and Explanation of Benefits (EOB) for any unexpected out-of-network charges.
→If you have questions about a bill, call your health insurance company first to understand their coverage determination.
→Visit CMS.gov/NoSurprises to learn more about the No Surprises Act and find contact information for the federal help desk.
→Keep detailed records of all medical bills, insurance paperwork, and communications with providers and your insurance company.

This lesson is legal information for educational purposes only, based on 45 C.F.R. § 149.410 (No Surprises Act). It is not legal advice and does not create an attorney-client relationship.