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Your Rights and Protections Against Surprise Medical Bills

Health care isn't always planned. In cases when you get emergency care or are treated by an out-of-network provider, you are protected from surprise billing or balance billing.

If you are a provider, learn how surprise billing affects you.

What is surprise billing (sometimes called “balance billing”)?

Whenever you see a 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 be responsible to pay the entire bill if you see a provider or visit a health care facility that isn’t in your network. Out-of-network providers (doctors or facilities providers and facilities that haven’t signed a contract with your health plan) may bill you for the difference between what your health 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. 

(See our Glossary for definitions of some of these and other common health insurance terms.)

If you believe you’ve been wrongly billed, you may contact Member Services at the number on the back of your BCBSNE member ID card. You may also contact the following state and federal agencies:

The Nebraska Department of Insurance
(only where State law applies)

PO Box 82089
Lincoln, NE 68501-2089
Phone: 877-564-7323 (in-state only)

The U.S. Department of Labor
200 Constitution Ave NW
Washington, D.C. 20210
Phone: 866-487-2365

When balance billing isn’t allowed, you have the following protections:
  • You are only responsible for paying your share of the cost per the in-network terms of your health benefit plan (such as copayments, coinsurance and deductibles you would pay if the provider or facility was in your 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 (preauthorization)
    • Cover emergency services from 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
  • Show the total amount you are responsible for paying on your explanation of benefits (EOB)
  • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit

You are protected from balance billing for:

Emergency services 
If you get emergency medical services from an out-of-network provider or facility, the most you are responsible for paying is your plan’s in-network cost-share amount (such as copayment and coinsurance); by law, you cannot 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. 

Providers in Nebraska may no longer balance bill Blue Cross and Blue Shield of Nebraska (BCBSNE) members for out-of-network medical care received in emergency situations. The Nebraska Out-of-Network Emergency Medical Care Act protects consumers from getting surprise bills from out-of-network providers or facilities for medical emergencies. Facilities are defined as general acute hospitals, satellite emergency departments or ambulatory surgical centers licensed per the Health Care Facility Licensure Act. This state mandate applies to all individual policies, fully insured group health plans, and non-ERISA self-funded groups.

Certain services at an in-network hospital or ambulatory surgical center 
Even when you get services at an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most you are responsible to pay 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. In other words, if you get any of these services from an out-of-network provider at an in-network facility, they cannot balance bill you, unless you give written consent and give up your protections.
You are never required to give up your protections from balance billing. 

Note that your costs of care will always be lowest when you get services from in-network providers and facilities. To find in-network providers, log into myNebraskaBlue.com or visit NebraskaBlue.com/Find-a-Doctor