Your Rights and Protections Against Surprise Medical Bills
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
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:
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
The state of Georgia and the federal government both have laws to protect
you from balance billing although they are a little different. State rules
only apply to fully insured commercial health insurance plans and some
government plans. Federal rules may also apply to commercial health insurance
in situations where you received health care services in another state,
your health insurance is regulated by a state other than Georgia or the
health care service you received is not regulated by the state law. Most
of the differences between the state and federal laws are in the way the
rules affect providers and health insurers, so you usually won’t
need to worry about that. However, the grievance processes are different,
as indicated on the government websites linked below.
Certain services at an in-network hospital, ambulatory surgical center
or other facility
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. Under Georgia
law this rule also applies to imaging centers, birthing centers, and similar
facilities in addition to hospitals and ambulatory surgical centers. If
you get other services at these in-network facilities, out-of-network
can’t balance bill you, unless you give written consent and give up your protections.
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.
The best way to find an in-network provider is to use the online provider
directory on your health plan’s website.
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
Your health plan generally must:
- Cover emergency services without requiring you to get approval for services
in advance (prior authorization). Under Georgia law, your health plan
cannot later deny such services because they don’t consider them
- 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
- Count any amount you pay for emergency services or out-of-network services
toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed:
Contact your provider and/or your health plan for an explanation. If they
can’t resolve your concerns, you can contact the
Georgia Office of the Commissioner of Insurance and Safety Fire online or by phone at (404) 656-2070.