Your Rights and Protections Against Surprise Medical Bills

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, like 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” 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.

“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. Surprise medical bills could cost thousands of dollarsdepending on the procedure or service.

You're protected from balance billing for:

Emergency services

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 deductibles). 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.

To view, download and read the St. Margaret’s Health Financial Assistance Plain Language Summary, please visit ourwebsite at https://aboutsmh.org/financial-assistance/.

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 beout-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.

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.

 

To view, download and read the St. Margaret’s Health Financial Assistance Plain Language Summary, please visit ourwebsite at https://aboutsmh.org/financial-assistance/.

When balance billing isn't allowed, you also have these protections:

  • 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

 

  • Generally, your health plan must:
    • Cover emergency services without requiring you to get approval for services in advance (also knownas “prior authorization”).
    • Cover emergency services by out-of-network
    • 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
    • Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket

 

If you think you’ve been wrongly billed, the federal phone number for information and complaints is 1-800-985-3059.

Visit https://www.cms.gov/nosurprises for more information about your rights under federal law.

SMH Peru And Spring Valley Will Be Closing All Current Operations As Of Friday, June 16, 2023 At 11:59 P.M.

This includes the Hospital, Clinics and other facilities at both locations.

All portals will be inaccessible after this time.

Patients needing emergency care should call 911.

To obtain a copy of your Medical Records please visit our Medical Records Request webpage and download and submit a request in writing.

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