The Consolidated Appropriations Act of 2021 (CAA) is a federal law that includes the No Surprises Billing Act as described below.

What is Balance Billing (sometimes called “surprise billing”)?

When you see a provider for healthcare services who doesn’t participate in your plan’s network, you may owe higher out-of-pocket costs (i.e., copayment, coinsurance, deductible). Non-participating providers may be permitted to bill you the difference between what they charge and what your health plan pays. This is known as “balance billing.” Sometimes when you go to an in-network facility you could receive care from a non-participating provider, and if that provider balance bills you, that is considered surprise billing.

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 or participating hospital or ambulatory surgical center (ASC), but you are unexpectedly treated by a non-participating provider.

When you get emergency services at a hospital or free-standing emergency room, or get treated by a non-participating provider at an in-network or participating hospital or ASC, you are protected from surprise billing or balance billing under federal law.

You are protected from surprise billing and balance billing for:

-Emergency Services

If you have an emergency medical condition and get emergency services from a non-participating provider or facility, the most you can be billed is your plan’s in-network cost sharing amount (i.e., copayments, and applicable coinsurance). Any cost sharing payments made with respect to your emergency service will be counted towards your in-network deductible and/or out of pocket maximum (the most you will pay for covered services during the year). Additionally, emergency services will be covered without needing approval in advance (prior authorization). You cannot be balanced billed for emergency services.

Additionally, there are protections for emergency services provided in Missouri to members of Missouri group health plans or Missouri direct pay members subject to the Missouri Unanticipated Out-Of-Network Care Law. This Missouri law controls whenever there is a conflict with the emergency services provisions of the Consolidated Appropriations Act of 2021 (CAA) as described in the paragraph above. If you receive emergency services from an out of-network health care professional provider at an in-network hospital in Missouri, you cannot be balance billed by any such provider who treated you from the time of your emergency admission to when you are discharged. Any cost sharing payments made with respect to your emergency service will be counted towards your in-network deductible and/or out of pocket maximum.

-Certain ancillary services at in-network hospitals or ambulatory surgical centers

When you get services from an in-network or participating hospital or ambulatory surgical center, certain ancillary providers there may be non-participating providers. The most those providers can bill you is your plan’s in-network cost sharing amount. Any cost sharing payments made for these services will be counted towards your in-network deductible and/or out of pocket maximum (the most you will pay for covered services during the year). This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist or intensivist services. These providers cannot ask you to consent to out of network charges and you cannot be balance billed for these services.

-Certain scheduled services at in-network hospitals or ambulatory surgery centers (ASC)

Additionally, you cannot be balance billed for any claims for non-emergency (scheduled) services covered under your plan from a non-participating provider at an in-network or participating facility unless you have a plan with out-of-network coverage AND have provided consent to be charged by the non-participating provider. If you provided consent for out of network charges your cost sharing could increase, and you could be billed the difference between what the provider/facility charged and what is covered under your plan’s benefits. If you do not provide consent for out of network charges, any cost-sharing payments made for these covered services will be counted towards your in-network deductible and/or out of pocket maximum (the most you will pay for covered services during the year).

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 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 non-participating 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 from non-participating providers
    • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility
    • 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 think you have been wrongly billed by a provider or facility, you can contact member services by calling the number on the back of your member ID card.

If you or someone you’re helping has questions about Blue KC, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1-844-395-7126.

At any point you can contact the Federal Agencies listed below. However, contacting Blue KC first is recommended for a more efficient and consumer-friendly experience.

If your insurance plan contract is issued in the state of Kansas:
Kansas Insurance Department
Phone: 785-296-3071
Consumer Hotline: 800-432-2484 (in state)

Centers for Medicare and Medicaid Services (CMS)
www.cms.gov/nosurprises
Phone: 1-800-985-3059

The U.S. Department of Health
Phone: 1-877-696-6775

The U.S. Department of Labor
Phone: 1-866-487-2365