YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS
(OMB Control Number: 0938-1401)
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 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, 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:
Emergency services
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 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.
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 protection 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.
Health Insurance Requirements for
Surprise Bills in Connecticut
Issue
Describe Connecticut’s requirements for health insurance coverage of surprise bills.
Summary
Connecticut law requires health carriers (e.g., insurers and HMOs) to (1) bill covered persons (e.g., insureds) at the in-network level for services rendered that resulted in a surprise bill and (2) provide them notice about surprise bills in policy documents and on the carriers’ websites. Surprise bills are generally those that are unexpected and charged by providers who are not in the carriers’ networks. The law prohibits health care providers from requesting payment, except for a copayment, deductible, coinsurance, or other out-of-pocket expense, from an insured for a surprise bill.
Surprise Bill
Definition
In Connecticut, a “surprise bill” is a bill for non-emergency health care services received by an insured for services rendered by the following:
an out-of-network clinical laboratory if the insured was referred by an in-network provider or
an out-of-network provider at an in-network facility during a service or procedure that was performed by an in-network provider or previously approved by the health carrier, and the insured did not knowingly elect to receive the services from the out-of-network provider (CGS § 38a-477aa(a)(6) as amended by PA 19-117 § 240).
A bill is not a surprise bill if an in-network provider is available but an insured knowingly elects to receive services from an out-of-network provider.
Coverage, Reimbursement, and Notice Requirements
By law, if an insured receives a surprise bill, he or she is only required to pay the coinsurance, copayment, deductible, or other out-of-pocket expense that would have applied had an in-network provider rendered the services. A health carrier must reimburse the out-of-network provider or insured, as applicable, for the services at the in-network rate under the plan as payment in full, unless the carrier and provider agree otherwise (CGS § 38a-477aa(c)).
The law also requires a health carrier to include a description of what constitutes a surprise bill (1) in the insurance policy, certificate of coverage, or handbook given to an insured and (2) prominently on its website (CGS § 38a-591b(d)).
Provider Penalty
It is a violation of the Connecticut Unfair Trade Practices Act (CUTPA) for a health care provider to (1) request payment, except for a copayment, deductible, coinsurance, or other out-of-pocket expense, from an insured for a surprise bill or (2) report an insured to a credit reporting agency for failure to pay a surprise bill when a health carrier is responsible for payment (CGS § 20-7f).
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 think you have been wrongly billed, you may contact the following agencies to file a complaint: Connecticut's Department of Insurance at 1-800-203-3447.
Visit https://portal.ct.gov/AG/Common/Complaint-Form-Landing-page for more information about your rights under Connecticut law.
Visit https://www.cms.gov/nosurprises for more information about your rights under Federal law.