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Last Updated: March 23, 2022
When you are transported by an out-of-network air ambulance provider, you are protected from surprise billing or balance billing. *
When you see a doctor or other health care provider such as an air ambulance provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or be obligated to pay the entire bill if you see a provider, such as an air ambulance 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.
If you have an emergency medical condition and get emergency services from an out-of-network provider, such as an air ambulance 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 (i.e. you can’t be billed more than your copayment, coinsurance, and/or a deductible) 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, emergency transportation, 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 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.
If you believe you’ve been wrongly billed, you have several options to raise your concerns:
The No Surprises Act gives you the right to appeal your health plan’s decisions to incorrectly deny or apply out-of-network cost sharing to surprise medical bills, first to the health plan, and then, if the plan upholds its decision, to an independent external reviewer.
Consumers can contact their state Consumer Assistance Program (CAP) created under the Affordable Care Act (ACA), which help educate privately insured consumers about their health plan coverage and rights. Further, they can assist you in resolving problems with health plans, including filing appeals.
*Please note the No Surprises Act does not apply to Ground Ambulance Providers.
**If you have limited benefit, or max benefit, plans. These provisions may not apply to your claim. Please contact one of our Patient Advocate to discuss your claim in detail.