Suzanne Manser, PhD
5050 NE Hoyt Street, Suite 522, Portland, OR 97213
(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.
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.
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.
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.
If you believe you’ve been wrongly billed, you may contact: The Oregon Board of Psychology: (503) 378-4154 or https://www.oregon.gov/psychology/pages/index.aspx
Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against- surprise-billing-providers-facilities-health.pdf for more information about your rights under Federal law.
Visit https://www.oregon.gov/oblpct/pages/index.aspx for more information about your rights under the state of Oregon.
This document was originally written by the Centers for Medicaid and Medicare (December 2021) and posted on their website. The No Surprises Law has already seen several revisions, so it is subject to change.
Centers for Medicare & Medicaid Services. (2021). Standard Notice and Consent Documents Under the No Surprises Act (For use by nonparticipating providers and nonparticipating emergency facilities beginning January 1, 2022). https://www.cms.gov/files/document/standard-notice-consent-forms-nonparticipating-providers- emergency-facilities-regarding-consumer.pdf