Effective Date: 1/1/2022
When you get emergency care or are treated by an out-of-network provider at an in-network hospital, you are protected from balance and surprise billing.
What is balance/surprise billing?
When you see a doctor or other healthcare provider, you may owe certain out-of-pocket costs, such as a copay, coinsurance and/or a deductible. You may have other costs, or must pay the entire bill, if you see a provider or visit a healthcare facility that isn’t in your Medical Mutual provider network.
Providers not in your Medical Mutual network may be permitted to bill you the difference between what Medical Mutual pays and the full amount charged for a service. This is called balance billing. The amount balance billed 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 the providers involved in your care—like when you have an emergency or when you visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
When are you protected from balance/surprise billing?
If you have a medical emergency and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your in-network copays and/or coinsurance. You can’t be balance billed for emergency services. This includes services you may get after you’re in stable condition unless you provide written consent and give up your protections not to be balanced billed.
Certain Services at In-network Hospitals or Outpatient Treatment Centers
When you get services from an in-network hospital or outpatient treatment center, certain providers may be out-of-network. The most those providers may bill you is your in-network copays and/or coinsurance. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist or intensive care services. These providers can’t balance bill you and may not ask you to give up your protections.
If you get other services at 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/surprise billing.
You aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
Ohio Revised Code sections 3902.50 through 3902.54 outlines protections Ohioans have against surprise medical bills for emergency and, in certain circumstances, unexpected out-of-network care.
Visit insurance.ohio.gov for details.
What are Your Other Protections When Balance/Surprise Billing is Not Allowed?
You are responsible for paying only the copays, coinsurance, and/or deductibles you would pay if the provider or facility was in-network. Medical Mutual will pay out-of-network providers and facilities directly.
Medical Mutual must:
- Cover emergency services without requiring you to get approval for services in advance
- Cover emergency services by out-of-network providers
- Base what you owe the provider or facility on what we would pay an in network provider or facility and show that amount on your explanation of benefits
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit
What Should You Do if You Believe You Have Been Wrongly Billed?
If you feel you have received a balance/surprise bill when you shouldn’t have, you may contact 1-800-985-3059.
Visit https://www.cms.gov/nosurprises for more information about your rights under federal law.