The No Surprises Act

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 typically 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 services you may get at the facility caring for you after you’re in stable condition.

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 certain 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.

Some states have their own laws relating to balance or surprise billing for out-of-network laboratory or pathology services that may be different from those described here, including the states listed below. The links below contain state specific balance billing information and resources, including contact information for state agencies that may be able to help you.

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.

When balance billing isn’t allowed, you also have these protections:

• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles) that you would pay if Verici Dx was an in-network provider. Your health plan will pay Verici Dx 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 think you’ve been wrongly billed: you may file a complaint with the federal government at https://www.cms.gov/nosurprises/consumers or by calling 1-800-985-3059; and/or file a complaint with your state balance billing regulator, if any, which is identified in the state-specific tabs.

Visit https://www.cms.gov/nosurprises for more information about your rights under federal law or visit your home state regulator’s website (included in state links above) for more information about your state balance billing rights.

Website: https://difi.az.gov/

Website: https://www.insurance.ca.gov/01-consumers/110-health/60-resources/NoSupriseBills.cfm or http://www.insurance.ca.gov/01-consumers/101-help/index.cfm

Website: https://coag.gov/file-complaint/

website: https://insurance.delaware.gov/services/filecomplaint/

Website: https://oci.georgia.gov/

website: https://www2.illinois.gov/sites/Insurance/consumers/Pages/default.aspx

websites: https://content.govdelivery.com/accounts/INDOI/bulletins/29ac870 
OR https://www.in.gov/idoi/consumer-services/

Websites: https://www.maine.gov/pfr/insurance/

Websites: www.insurance.maryland.gov 
or https://insurance.maryland.gov/Consumer/Documents/publications/AssignmentofBenefitsFAQ.pdf

Websites: https://www.michigan.gov/difs/0,5269,7-303-13222_13250-561696–,00.html; 
https://www.michigan.gov/DIFScomplaints

Websites: http://www.mid.ms.gov 
or http://www.mid.ms.gov/healthcare/questionsanswers/TopicTwo.pdf

website: https://insurance.mo.gov/consumers/health/managingcost.php

Websites: www.doi.nebraska.gov; 
https://doi.nebraska.gov/sites/doi.nebraska.gov/files/doc/ConsumerFactSheetBalanceBillingandOutofNetworkProviders.pdf 
or https://doi.nebraska.gov/consumer/consumer-assistance

website: https://doi.nv.gov/Consumers/Health_and_Accident_Insurance/Balance_Billing_FAQs/

websites: https://www.nh.gov/insurance/consumers/ 
or https://www.nh.gov/insurance/consumers/documents/20211210-nsa-faq-consumers-producers.pdf

website: https://www.state.nj.us/dobi/division_consumers/insurance/outofnetwork.html

website: https://www.osi.state.nm.us/

Websites: http://www.dfs.ny.gov or https://www.dfs.ny.gov/consumers/health_insurance/surprise_medical_bills

website: https://insurance.ohio.gov/

Website: https://www.oregon.gov/dcbs/pages/index.aspx

Website: https://www.pa.gov/guides/healthcare/ or 
https://pennpirg.org/sites/pirg/files/resources/PennPIRG%20Surprise%20Billing%20tip%20sheet_formatted.docx_.pdf

website: https://www.tdi.texas.gov/tips/texas-protects-consumers-from-surprise-medical-bills.html

Websites: https://scc.virginia.gov/pages/Balance-Billing-Protection;
Scc.virginia.gov/pages/File-Complaint-Consumers

websites: https://www.insurance.wa.gov/file-complaint-or-check-your-complaint-status or
https://www.insurance.wa.gov/what-consumers-need-know-about-surprise-or-balance-billing

website: https://www.wvinsurance.gov/