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 dollars depending on the procedure or service.
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.
If you are a Nevada resident, Nevada law also protects patients covered by health benefit plans regulated by the state, the Public Employee’s Benefits Program and third parties that opt into the prohibition from balance billing for medically necessary emergency services provided by an out-of-network provider.
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 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.
When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.
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.
If you are a Nevada resident, Nevada law requires that the patient pay only their in-network cost sharing amounts. This law does not apply to:
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 directly.
Generally, your health plan must:
If you think you’ve been wrongly billed, you may contact the No Surprises Helpdesk at 1- 800-985-3059 and/or the Department of Business and Industry, Nevada Division of Insurance at 1-888-872-3234.
Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law and
https://doi.nv.gov/Consumers/Health_and_Accident_Insurance/Balance_Billing_FAQs/ for more information about your rights under Nevada law.