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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 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.

  • Balance Billing occurs when out-of-network providers bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This amount is likely more than in-network costs 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:

1. Emergency Services: 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 protection includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balance billed for these post-stabilization services.

2. 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 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.

Important Note: You’re 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.

Your Additional Protections When Balance Billing Isn’t Allowed

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.

Michigan State Law for Patients in State-Regulated Health Plans

Michigan law establishes protections for patients in state-regulated health plans. As an example, out-of-network providers providing care to non-emergency patients must make certain disclosures to patients such as the following:

  • That your health insurance may not cover all services the out-of-network provider will offer.

  • A good faith estimated cost of services to be provided.

  • That you may ask the services to be performed by an in-network provider.

Questions Regarding Your Bill?

If you have received a Center for Oral Surgery + Dental Implants bill and have questions, please contact our billing department:

  • Phone: 616-361-7327 Extension 2

  • Hours: Monday – Friday, 8:00 AM – 4:45 PM

Additional Resources

For more information about your rights: