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 or non-par” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network or non-par providers may be permitted to bill you for the difference between what your plan agreed 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 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 or non-par.
You are protected from balance billing for:
If you have an emergency medical condition and get emergency services from an out-of-network or non-par 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 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.
Puerto Rico Law No. 134 of September 1, 2020 “Law for the Protection of Patients from Surprise Medical Bills”, as well as local Law No. 194-2000 “The Patient’s Bill of Rights and Responsibilities”, as amended, provides that if you receive emergency services from an out-of-network or non-par provider, the provider that offers those services may not billed you in excess of any applicable deductible, copayment, or coinsurance for the services provided, according to your coverage.
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network or non-par. In these cases, the most those providers may bill you for non-emergency auxiliary services 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 or non-par 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 care out-of-network. 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 file a claim at the Office of the Insurance Commissioner of Puerto Rico.
Edificio World Plaza Teléfono:787-304-8686
268 Av. Muñoz Rivera Toll Free:1-888-722-8686
San Juan, PR 00918 Fax: 787-273-6082
Piso 9 www.ocs.pr.gov
Visit https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/no-surprises-act or https://www.cms.gov/nosurprises/Policies-and-Resources/Overview-of-rules-fact-sheets for more information about your rights under federal law.