When you receive emergency care you are protected from balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, or deductible. You may have additional 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 to provide services. Out-of-network providers can bill you for the difference between what your plan agrees 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 plan’s deductible or 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 at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for emergency services:

If Wake Emergency Physicians, PA (“WEPPA”) is out of network with your health plan and you receive emergency services from a WEPPA provider for an emergency medical condition, the most that we may bill you is your health plan’s in-network cost-sharing amount (such as deductibles, copayments, and coinsurance). WEPPA cannot balance bill you for these emergency services.

Under North Carolina law, your health plan cannot require you to pay more for the emergency services you receive if we are NOT in-network with your health plan than it can if we ARE in-network with your insurance plan.

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.

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 facilities directly.
• Your health plan generally must:
  • Cover emergency services without requiring you to get approval for services in advance (prior authorization).
  • 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 of benefits.
  • 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, you may contact the federal Department of Health and Human Services at 1-800-985-3059 and/or the North Carolina Department of Insurance at 1-855-408-1212.

Visit www.cms.gov/nosurprises for more information about your rights under federal law. Visit www.ncdoi.gov for more information about your rights under North Carolina law.

 

The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.