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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 in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

Participants, beneficiaries, enrollees, or covered individuals in group health plans or group health insurance coverage, including Federal Employees Health Benefits (FEHB) plans, please take note of 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-pockets costs, such as a copayment, coinsurance and/or a deductible. You may have other costs or have to pay the difference between the amount your health plan pays for the items and services and 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. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charges 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 towards 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:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most you will have to pay the provider or facility 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 a stable condition unless you give written consent and give up your protections not to be balance billed for these post-stabilization services.

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 you will have to pay these providers 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.

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. Please contact the member services phone # on your insurance card to find an in-network provider.

When balance billing isn’t allowed, you also have these 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 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
    • 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 towards your deductible and out-of-pocket limit

If you believe you’ve been wrongly billed, you may contact the West Virginia Offices of the Insurance Commissioner at https://www.wvinsurance.gov/Consumer_Services or by phone at 304-558-3386 or Toll- free in WV: 1-888-TRY-WVIC.

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

The practices of OCLI Vision offer eye care services at locations throughout Connecticut, New Jersey, New York, Pennsylvania and West Virginia and specialize in primary vision care, LASIK, cataract surgery, glaucoma, diabetic eye care, and other services for patients in the Northeast. These locations include practice locations of OCLI Vision as well as the practice locations of other vision services providers and ambulatory surgery centers supported by the administrative services of Spectrum Vision Partners. Each location is identified by the vision service provider or company operating at the location.

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