No Surprises Act

Your Rights and Protections Against Surprise Medical Bills

When you receive emergency care at a hospital that is not in your health plan network or are treated by an out-of-network clinician, you are protected from what is known as "balance billing" or "surprise billing." This means you should not be charged more than your plan's copayments, coinsurance and/or deductible.

What is "balance billing"/"surprise billing"?

When you see a doctor or other health care clinician, you may owe certain out-of-pocket costs, such as a copayment, coinsurance and/or a deductible. You may have added costs or have to pay the entire bill if you see a provider or visit a health care facility that is not in your health plan’s network.

"Out-of-network" refers to clinicians and facilities that have not signed a contract with your health plan to provide services. Out-of-network clinicians may be allowed 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 likely is more than in-network costs for the same service and may not count toward your annual out-of-pocket limit.

"Surprise billing" refers to an unexpected balance bill. This can happen when you are not able to control who is involved in your care, such as 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 clinician.

You are protected from balance billing for:

  • Emergency services: If you get emergency services from an out-of-network clinician or facility, the most the clinician/facility may bill you is your plan’s in-network cost-sharing amount (i.e. copayments, coinsurance and/or deductible). You cannot be balance billed for these emergency services. This includes services you may receive after you no longer need emergency care, unless you give written consent and give up your protections not to be balanced billed for these 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 clinicians there may be out-of-network. These clinicians can only bill you 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 clinicians cannot 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 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. In addition, you are not required to get care out-of-network; you can choose a clinician or facility in your plan’s network.

When balance billing is not allowed, you also have the following protections:

  • You only are responsible for paying your share of the cost (i.e. copayments, coinsurance and deductibles you would pay if the clinician or facility was in-network). Your health plan will pay any added costs directly to out-of-network clinicians and facilities.
  • Generally, your health plan generally must:
    • Cover emergency services without requiring you to get approval for services in advance (known as "prior authorization");
    • Cover emergency services by provided by out-of-network clinicians;
    • Base your share of the cost on what it would pay an in-network clinician or facility and show that amount in your explanation of benefits; and
    • Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

If you believe you have been billed wrongly, you may contact the Maine Bureau of Insurance by calling (207) 624-8475, or 1-800-300-5000 (toll-free).

For more information about your rights under federal law, visit the Maine Bureau of Insurance website.

For more information about your rights under Title 22: Health and Welfare, Subtitle 2: Health, Part 4: Hospitals and Medical Care, Chapter 401: General provisions, visit the Maine Legislature website.

View/print a copy of this information