Sus derechos y protecciones contra facturas médicas sorpresa

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing.

En estos casos, no se le debe cobrar más que los copagos, coseguro y/o deducible de su plan.

Recursos

¿Qué es la "facturación de saldo" (a veces llamada "facturación sorpresa")?

Cuando consulta a un médico u otro proveedor de atención médica, es posible que deba ciertos gastos de su bolsillo, como un copago, un coseguro y/o un deducible. Es posible que tenga costos adicionales o que tenga que pagar la factura completa si ve a un proveedor o visita un centro de atención médica que no está en la red de su plan de salud.

“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.

La "facturación sorpresa" es una factura de saldo inesperada. Esto puede suceder cuando no puede controlar quién está involucrado en su atención, como cuando tiene una emergencia o cuando programa una visita en un centro dentro de la red pero recibe un tratamiento inesperado por parte de un proveedor fuera de la red. Las facturas médicas sorpresa pueden costar miles de dólares según el procedimiento o servicio.

Servicios de emergencia

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 deductible). 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 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.

When balance billing isn’t allowed, you also have these 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. 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 directly.

Generally, your health plan must:

  • Cubrir los servicios de emergencia sin necesidad de obtener aprobación por adelantado para los servicios (también conocido como "autorización previa")
  • Cobertura de servicios de emergencia por parte de proveedores fuera de la red
  • Base lo que le debe al proveedor o centro (costo compartido) en lo que le pagaría a un proveedor o centro dentro de la red y muestre esa cantidad en su explicación de beneficios
  • Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit

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