Important Legal Notices for ConnectiCare Members
Your Rights and Protections Against Surprise Medical Bills
|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.|
What do “balance billing” and “surprise billing” mean?
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 in- network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
If you have an emergency medical condition and get emergency services from an out-of- network provider or facility, the most the provider or facility may bill you is your plan’s in- network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes certain post-stabilization services you may get unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
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.
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.
If you are a member enrolled in a Connecticut insured plan, you may have surprise billing protections under state law for a bill by an out-of-network laboratory upon referral by an in-network provider.
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:
- Cover emergency services without requiring you to get approval for services in advance (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 deductible and out-of-pocket limit.
If you are a member enrolled in a Connecticut insured plan and if you believe you’ve been wrongly billed, or you would like more information about your rights under Connecticut law, you may contact the State of Connecticut Insurance Department, at https://portal.ct.gov/CID/General-Consumer-Information/Consumer-Services.
If you are a member enrolled in a Massachusetts insured plan and you believe you’ve been wrongly billed, you may file a complaint with the federal government at https://www.cms.gov/nosurprises or by calling 800-985-3059; and/or file a complaint with the Massachusetts Division of Insurance at www.mass.gov/how-to/file-a-health-care-complaint or by calling 617-521-7794.
If you are enrolled in a self-insured plan and you believe you’ve been wrongly billed or need more information about your rights under federal law, call 800-985-3059 or visit http://www.cms.gov/nosurprises.
Visit https://www.cms.gov/nosurprises for information about your rights under federal law.