The federal No Surprises Act enacted Surprise Billing protections for individuals effective Jan. 1, 2022. Under the No Surprises Act, providers are prohibited from billing additional amounts beyond the member's copayment, coinsurance or deductible (sometimes referred to as Balance Billing) if an out-of-network provider performs emergency services at an out-of-network facility or if an out-of-network provider furnishes services at an in-network facility. In addition to the federal Surprise Billing protections, certain states have also mandated surprise billing protections for consumers:
| State | Surprise billing protections * |
|---|---|
| Arizona | Members are allowed to request mediation of a settlement for an out-of-network benefit claim if the member responsibility is over $1,000, the health benefit claim is for a medical service or supply provided by a provider in a facility that is a preferred provider, and the member received a surprise out-of-network bill. |
| California | Emergency room health care providers are prohibited from balance billing members even if they are out of network. If a member receives covered services (non-emergency services) from an in-network facility where they are treated by an out-of-network provider, the member will pay the in-network cost. |
| Colorado | Health plans shall impose the same cost-sharing for emergency out-of-network services as it would impose for in-network emergency services. State law has been updated to mirror the Federal No Surprises Act. |
| Connecticut | A health plan shall not impose a coinsurance, copayment, deductible, or other out-of-pocket expense that is greater than the coinsurance, copayment, deductible, or other out-of-pocket expense that would be imposed if such services were rendered by an in-network provider. In-network member billing will occur for a bill for health services—other than emergency services—received by an insured for services rendered by an out-of-network provider, where such services were rendered at an in-network facility, during a service/procedure performed by an in-network provider or during a service/procedure previously approved/authorized by the health plan and the member did not knowingly elect to obtain such services from the out-of-network provider. |
| Delaware | Out-of-network providers are prohibited from balance billing a member for emergency services. Health plans are required to provide covered members for emergency care services performed by an out-of-network provider at an agreed-upon or negotiated rate, regardless of if they are in-network. |
| Florida | A member is not liable for payment of fees to an out-of-network provider for covered emergency services, other than applicable copayments, coinsurance, and deductibles that would be applicable for in-network services. A member is not liable for payment of fees to an out-of-network provider, other than applicable copayments, coinsurance and deductibles, for covered nonemergency services that are provided in a facility that has a contract for the nonemergency services with the health plan which the facility would otherwise be obligated to provide under contract with the health plan and provided when the member does not have the ability and opportunity to choose an in-network provider at the facility who is available to treat the member. |
| Georgia | Health plans are required to pay for emergency services at the same benefit level, regardless of whether the facility is in-network or out-of-network. The out-of-network emergency provider is prohibited from billing the member anything more than the in-network deductible, coinsurance, copayment or other cost-sharing amount. |
| Illinois | Health plans are required to provide coverage for emergency services at the same benefit level, regardless of whether the facility is in-network or out-of-network. When a member uses participating health care facility and, due to any reason, covered ancillary services are provided by a nonparticipating provider during the visit, a health plan cannot bill the member greater out-of-pocket costs than the member would have incurred with an in-network provider for the services. |
| Indiana | An out-of-network provider who provides health care services to a member in an in-network facility may not charge more for the health care services provided to a member than allowed by the member's network plan unless, at least five days before the health care services are scheduled to be provided, the member is provided a statement that informs the member that the facility or provider intends to charge more than allowed under the network plan and sets forth an estimate of the charge and the member consents to the charge. |
| Iowa | A health plan that provides coverage for emergency services is responsible for charges for emergency services provided to a member, including services furnished outside any contractual provider network or preferred provider network. |
| Maine | For covered emergency services rendered by an out-of-network provider, a health plan shall require a member to pay only the applicable coinsurance, copayment, deductible or other out-of-pocket expense that would be imposed for health care services if the services were rendered by a network provider. If the member is subject to coinsurance, then the health plan shall calculate the coinsurance amount based on the median network rate for that health care service. |
| Maryland | Out-of-network providers are prohibited from billing a member for any amount beyond in-network level of cost-sharing for emergency services. |
| Massachusetts | An out-of-network provider is prohibited from billing a member for any amount beyond in-network level of cost-sharing for emergency services. |
| Michigan | An out-of-network provider may not collect or attempt to collect from a member any amount other than the applicable in-network coinsurance, copayment, or deductible for emergency services. |
| Minnesota | If emergency services are provided by an out-of-network provider, with or without prior authorization, the health plan shall not impose coverage restrictions or limitations that are more restrictive than apply to emergency services received from an in-network provider. Cost-sharing requirements that apply to emergency services received out-of-network must be the same as the cost-sharing requirements that apply to services received in-network. |
| Missouri | A health plan shall cover emergency services necessary to screen and stabilize an enrollee, as determined by the treating emergency department health care provider, and shall not require prior authorization of such services. Coverage of emergency services shall be subject to applicable copayments, coinsurance and deductibles. |
| Nebraska | If a member receives emergency services at an in-network or out-of-network health care facility, the health plan shall ensure that the member incurs no greater out-of-pocket costs than the member would have incurred with an in-network provider for the services. |
| Nevada | A member is not responsible for paying an amount that exceeds the copayment, coinsurance or deductible requires for emergency services provided by an out-of-network provider. |
| New Hampshire | If a member receives anesthesiology, radiology, emergency medicine, or pathology services, the provider shall not balance bill for fees or amounts other than copayments, deductibles, or coinsurance, if the service is performed in a hospital or ambulatory surgical center that is in-network under the patient's health insurance plan. The prohibition shall apply whether or not the health care provider is contracted with the member's health plan. |
| New Jersey | If a member receives medically necessary services at any health care facility on an emergency or urgent basis, the facility shall not bill the member in excess of any deductible, copayment, or coinsurance amount applicable to in-network services pursuant to the member's health benefits plan. |
| New Mexico | A health plan may impose cost-sharing or limitation of benefits requirement for emergency care performed by an out-of-network provider only to the same extent that the copayment, co-insurance or limitation of benefits requirement applies for in-network providers and is documented in the health plan contract. |
| New York | For emergency services, a health plan shall ensure that the member will not incur greater out-of-pocket costs for the emergency services, including inpatient services which follow an emergency room visit, than the member would have incurred with a participating provider. |
| North Carolina | Coverage of emergency services provided by an out-of-network provider shall be subject to coinsurance, copayments, and deductibles applicable under the health benefit plan. The health plan may not impose cost-sharing for emergency services that differs from cost-sharing that would have been imposed if the provider furnishing the services were a provider contracted with the health plan. |
| Ohio | For unanticipated out-of-network care provided at an in-network facility, a provider shall not bill a covered person for the difference between the health plan issuer's reimbursement and the provider's charge for the services. For emergency services provided at an out-of-network emergency facility, neither the emergency facility nor an out-of-network provider shall bill a covered person for the difference between the health plan issuer's reimbursement and the emergency facility's or the provider's charge for the services. |
| Oregon | An out-of-network provider may not bill a member for emergency services or other inpatient or outpatient services provided at an in-network health care facility. The health plan shall reimburse the out-of-network provider for emergency services or other covered inpatient or outpatient services provided at an in-network health care facility as determined by the Oregon Division of Financial Regulation. |
| Rhode Island | Any cost-sharing (e.g., copayment and coinsurance) imposed on a member by a health plan for out-of-network emergency services cannot exceed the cost-sharing requirement imposed with respect to a member if the services were provided in-network. |
| Texas | For emergency services, a member does not have financial responsibility for an amount greater than an applicable copayment, coinsurance, and deductible under the member's health plan. |
| Utah | Cost-sharing requirements for out-of-network emergency services may not exceed the cost-sharing requirement imposed for in-network emergency services furnished. |
| Vermont | The state has aligned its statutory requirements with the No Surprises Act and providers are prohibited from balance billing for out-of-network emergency room services. Additionally, providers are prohibited from balance billing a Medicare beneficiary. |
| Virginia | If a member receives emergency services from an out-of-network provider, or nonemergency services involving surgical or ancillary services at an in-network facility by an out-of-network provider, then the member is obligated to pay the in-network cost-sharing requirement as specified in the member's health plan contract. The member's obligation is determined by using the health plan's median in-network contracted rate for the same or similar service in the same or similar geographical area. |
| Washington | If a member receives emergency services from an out-of-network provider, or any nonemergency surgical or ancillary services at an in-network facility from an out-of-network provider, the member is obligated to pay the in-network cost-sharing amount specified in the member's health plan contract. Washington has expanded balance billing protections to extend to behavioral emergency services providers, as defined by the state. |
| West Virginia | Coverage of emergency services shall be subject to coinsurance, copayments, and deductibles applicable under the health benefit plan. |
| No State Surprise Billing Protections** | Alabama, Alaska, Arkansas, District of Columbia, Hawaii, Idaho, Kansas, Kentucky, Louisiana, Montana, North Dakota, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Wisconsin, and Wyoming. |
*State surprise billing protections may not apply to all plans.
**Federal surprise billing requirements apply to services in the absence of a state requirement.
Last updated: 6/30/22
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