Balance Billing

The bill after the bill

When you see an in-network provider, they agree to accept your plan's negotiated rate as payment in full. You pay your share, the plan pays the rest, and that is the end of it.

Out-of-network providers have made no such agreement. If they charge more than your plan allows, they can send you a bill for the leftover amount. That leftover is the balance bill, and it usually does not count toward your deductible or out-of-pocket maximum.

Example

Marcus, a self-employed electrician, has a PPO with out-of-network benefits. He schedules a planned procedure with an out-of-network specialist.

• The specialist charges $6,000.
• His plan's allowed amount for that service is $3,500.
• Marcus pays his out-of-network coinsurance on the $3,500, and the plan pays its share.
• The specialist then bills Marcus for the remaining $2,500.

That $2,500 is a balance bill. Because Marcus chose an out-of-network provider for scheduled care and signed a consent form, federal protections did not apply.

When federal law protects you

The No Surprises Act, in effect since 2022, bans balance billing in the situations where people have the least control:

• Emergency services, at any hospital or freestanding emergency room, in or out of network.
• Non-emergency care at an in-network facility from out-of-network providers you did not choose, such as anesthesiologists, radiologists, pathologists and assistant surgeons.
• Air ambulance services.

In those cases you owe only your normal in-network cost sharing. The provider and insurer settle the rest between themselves.

Where gaps remain

• Planned out-of-network care you agree to. Providers can ask you to sign a notice and consent form waiving protections for certain scheduled services.
• Ground ambulance rides are not fully covered by the federal law, though some states add protections.
• Plans outside federal rules. Coverage that is not regulated as health insurance, such as health sharing arrangements, may not carry the same protections.

Marketplace vs private plans

ACA-compliant Marketplace and off-exchange plans follow the No Surprises Act. Because many Marketplace plans in Florida are HMOs or EPOs, out-of-network care outside emergencies is usually not covered at all, so balance billing tends to come up less often for planned care. Private PPO plans with out-of-network coverage give more choice, which also means more chances to face a balance bill if you go outside the network by choice. Check the rules on any non-ACA plan you consider.

How to protect yourself

• Confirm network status for the facility and every provider before a planned procedure.
• Do not sign consent forms without understanding them.
• If you get an unexpected bill for emergency care, contact your insurer and the provider and cite the No Surprises Act.

For more on network choices, read our comparison of private vs Marketplace plans for the self-employed and how to read a health insurance quote. To review plans with strong network coverage, request a quote.