Effective January 1, 2022
Your rights and protections against surprise medical bills
This Disclosure Notice includes Main Line Health Hospitals, Main Line Health Care Providers and the services provided by the following physician practices:
- Main Line Emergency Medical Associates
- Radiology Associates of the Main Line
- Pathology Associates of the Main Line
- Children's Hospital of Philadelphia (CHOP)
- United Anesthesia
- Jefferson University Physicians
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
What is balance billing? (Sometimes called "surprise billing")
When you see a doctor or health care provider, you may own certain out-of-pocket costs, such as co-payment, co-insurance, and/or deductibles. You may have other costs or have to pay the entire bill if you see a doctor or visit a 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 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.
You are protected from balance billing for:
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan's in-network cost-sharing amount (such as co-payment and co-insurance). You can't 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.
Certain services at an in-network hospital and ambulatory surgical center
When you get services at an in-network hospital or ambulatory surgical center, there may be doctors working at that facility that may be out-of-network with your health plan. In these cases, the most these providers may bill you is your plan's in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, 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 are never required to give up your protections from balance billing. You also are not 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 (co-payments, co-insurance, 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 directly.
- 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 providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay in-network provider or facility and show that amount in 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.
If you believe you have been wrongly billed, you may contact the following Agencies for assistance:
Pennsylvania Department of Insurance
1326 Strawberry Square
Harrisburg, PA 17120
Dept. of Insurance (Insurance billing issues):1.877.881.6388
Attorney general health care section (Provider billing issues): 1.717.705.6938