Your Rights and Protections Against
Surprise Medical Bills and Balance Billing
In Washington State
When you get emergency care or get treated by an out-of-network provider at an in-network hospital orambulatory 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 other health care provider, you may owe certain out-of-pocket costs, such asa copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill
if you see a provider or visit a health care 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 islikely more than in-network costs for the same service and might not count toward your annual out-ofpocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involvedin 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.
Insurers are required to tell you, via their websites or on request, which providers, hospitals, andfacilities are in their networks. Hospitals, surgical facilities, and providers must tell you which provider
networks they participate in on their website or on request.

You are protected from balance billing for:
Emergency Services
If you have an emergency medical condition, mental health or substance use disorder condition andget 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 copayments and coinsurance). You
can’t be balance billed for these emergency services. This includes care you receive in a hospital and in
facilities that provide crisis services to people experiencing a mental health or substance use disorderemergency. You can’t be balance billed for these emergency services, including services you may getafter you’re in stable condition.

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 providers
there may be out-of-network. In these cases, the most these providers may bill you is your plan’s innetwork cost-sharing amount.

You also aren’t required to get care out-of-network. You can choose aprovider or facility in your plan’s network.

When can you be asked to waive your protections from balancebilling:
Health care providers, including hospitals and air ambulance providers, can never require you to giveup your protections from balance billing.
If you have coverage through a self-funded group health plan, in some limited situations, a provider can
ask you to consent to waive your balance billing protections, but you are never required to give yourconsent. Please contact your employer or health plan for more information.

When balance billing isn’t allowed, you also have the following
protections:•You are only responsible for paying your share of the cost (like the copayments, coinsurance,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:oCover emergency services without requiring you to get approval for services in advance(prior authorization).

oCover emergency services by out-of-network providers.

oBase what you owe the provider or facility (cost-sharing) on what it would pay an innetwork provider or facility and show that amount in your explanation of benefits.

oCount any amount you pay for emergency services or out-of-network services toward
your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may file a complaint with the federal government at
https://www.cms.gov/nosurprises/consumers or by calling 1-800-985-3059; and/or file a complaint withthe Washington State Office of the Insurance Commissioner at their website or by calling 1-800-5626900.
Visit https://www.cms.gov/nosurprises for more information about your rights under federal law.
Visit the Office of the Insurance Commissioner Balance Billing Protection Act website for moreinformation about your rights under Washington state law.