Your rights and protections against surprise medical bills

When you see a doctor or another health care provider, you may owe certain out-of-pocket costs — a copayment, coinsurance, or your deductible. If the provider or facility isn't in your health plan's network, you may owe more, or even the entire bill.

"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 — a practice called balance billing. That amount is usually more than the in-network cost for the same service, and it might not count toward your plan's deductible or annual out-of-pocket limit.

A surprise bill is an unexpected balance bill — one that arrives when you couldn't control who was involved in your care. It happens in two classic scenarios: you have an emergency, or you schedule a procedure at an in-network facility and are treated, without knowing it, by an out-of-network provider. Depending on the procedure or service, a surprise bill can run into the thousands of dollars. Federal law now protects you in both scenarios.

If you have an emergency medical condition and receive 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 — the same copayments, coinsurance, and deductible you'd owe in network. You cannot be balance billed for emergency care, period.

The protection extends to services you receive after you're stabilized — so-called post-stabilization care — unless you give written consent specifically giving up your protections for those services. No one can pressure you into signing; that choice is always yours.

Even when the hospital or ambulatory surgical center is in your network, some of the individual providers working inside it may not be. This is the situation surgical patients run into most often — you chose your surgeon and your facility carefully, but you never picked the anesthesiologist or the pathologist. The law closes that gap:

• Ancillary providers can never balance bill you. For emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, and intensivist services at an in-network facility, the most those providers can bill you is your plan's in-network cost-sharing amount. They also may not ask you to sign away this protection — a waiver for these services is never valid.
• Other out-of-network providers can't balance bill you either, unless you give written consent and voluntarily give up your protections.

Here's what that looks like at a glance:

You are never required to give up your protection from balance billing. You also aren't required to accept out-of-network care at all — you can always choose a provider or facility in your plan's network.

Whenever the balance-billing protections apply, the law also guarantees how your plan must handle the claim:

• You pay only your share — the copayments, coinsurance, and deductible you would owe if the provider or facility were in-network. Your health plan pays any additional amount directly to the out-of-network provider or facility, not through you.
• Emergency services must be covered without prior authorization — your plan can't require advance approval before treating an emergency.
• Emergency services by out-of-network providers must be covered.
• Your cost-sharing must be based on in-network rates — what your plan would pay an in-network provider or facility — and that amount must be shown in your explanation of benefits.
• Every dollar you pay counts. Amounts you pay for emergency services or protected out-of-network services must count toward your in-network deductible and out-of-pocket limit.

A joint replacement involves exactly the mix of providers this law was written for: your surgeon, an anesthesiologist, the facility, pathology, radiology, and laboratory services. That's why Dr. Morton's team doesn't leave billing to chance. Whether your surgery takes place at The Queen's Medical Center in Honolulu, Adventist Health Castle, or Hilo Community Surgery Center on the Big Island, the office verifies your benefits and handles prior authorization before your procedure — so you know what to expect long before any bill arrives. Patients paying without insurance can compare transparent self-pay packages, and the cost guide explains the full landscape of what hip and knee replacement actually costs in Hawai'i.

Don't pay a bill that doesn't look right — question it. Start with the people who know your case:

• Call Dr. Morton's office at (808) 439-6201. The billing team will review the charge against your plan and your visit.
• Call the federal No Surprises Help Desk at 1-800-985-3059 for information about your rights or to file a complaint under federal law.
• Visit cms.gov/nosurprises/consumers for the full details of your protections under federal law.