Plans are generally not required to cover care received from an out-of-network (OON) provider. When they do, it is often with much higher cost-sharing than for in-network services.

There are some federal and state protections that may prevent providers from “balance billing” you— the difference between what your insurance covers and what the provider actually bills— in certain situations. Federal protections against balance billing generally apply in two situations:

1. If you received emergency or post-emergency stabilization care at an OON facility or from an OON provider; or

2. If you unintentionally received care from an OON provider while at an in-network hospital (for instance, if the anesthesiologist or other specialist isn’t in your plan’s network).

You can learn more about federal protections here.

When you get care OON, your insurer might set a different deductible and might not count these costs towards your annual out-of-pocket limit. OON providers also don’t have to limit their charges to what your insurer considers reasonable, which means you could end up paying balance billing charges. If you received a surprise medical bill after choosing an OON provider because you felt it was necessary (perhaps because the in-network options didn’t meet your needs) or you experienced one of the two situations outlined above, you can ask for an internal appeal and external review. Contact your state insurance department for more information on the appeals process, to see if there are programs to help you with your appeal, and to file a complaint about a surprise medical bill. You can also visit the No Surprises Help Desk or call 1-800-985-3059 to submit a complaint or ask any questions.