Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or are treated by an out-of-network provider at an in-network facility, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.
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 healthcare 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.
Connecticut balance billing law applies to health plans regulated by Connecticut’s Department of Insurance and has similar protections to those provided under the federal No Surprises Act. For more information, go to Connecticut Department of Insurance website at https://portal.ct.gov/CID/General-Consumer-Information/No-Surprises-Act.
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network facility, 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.
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.
Connecticut balance billing law applies to health plans regulated by Connecticut’s Department of Insurance and has similar protections to those provided under the federal No Surprises Act. For more information, go to Connecticut Department of Insurance website at https://portal.ct.gov/CID/General-Consumer-Information/No-Surprises-Act.
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
- 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
- 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
- Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket
What is a “good faith estimate?”
A “good faith estimate” outlines the expected cost of any non-emergency items or services. Effective January 1, 2022, healthcare providers must give clients who don’t have insurance or are not using their insurance to pay for their healthcare an estimate of their bill for expected non-emergency items and services.
A good faith estimate must be given in writing at least one business day before medical services are given, unless the appointment is scheduled less than three days in advance. The estimate is based on information known at the time the estimate was created and may include costs related to your visit such as medical tests, medications used during care, equipment, and hospital fees.
If you receive a bill that is at least $400 more than the good faith estimate, you can dispute the bill through the U.S. Department of Health & Human Services. There is a fee to dispute bills.
If you think you’ve been wrongly billed, you may contact:
Connecticut Department of Insurance: https://portal.ct.gov/CID/Consumer-Affairs/File-a-Complaint-or-Ask-a-Question; or Consumer Helpline: 800-203-3447 or 860-297-3900. By email insurance@ct.gov
Or you can file a report online.
The State of Connecticut Office of the Healthcare Advocate at 866-466-4446 or Healthcare.advocate@ct.gov.
Visit https://www.cms.gov/nosurprises/consumers for more information about your rights under federal law. The federal phone number for information and complaints is: 1-800-985-3059