Last updated on July 31, 2019.
“Balance bills” primarily occur in two circumstances: 1) when an enrollee receives emergency care either at an out-of-network facility or from an out-of-network provider, or 2) when an enrollee receives elective nonemergency care at an in-network facility but is inadvertently treated by an out-of-network health care provider. Since the insurer does not have a contract with the out-of-network facility or provider, it may decide not to pay the entirety of the bill. In that case, the out-of-network facility or provider may then bill the enrollee for the balance of the bill. No federal law currently limits this practice, but 28 states have enacted laws to protect enrollees from it.
Source: M. Kona, et al, Center on Health Insurance Reforms, Health Policy Institute, Georgetown University. Please contact Maanasa Kona for questions about this map.
- Jack Hoadley, Kevin Lucia, and Maanasa Kona, "States Are Taking New Steps to Protect Consumers from Balance Billing, But Federal Action Is Necessary to Fill Gaps," To the Point (blog), Commonwealth Fund, July 15, 2019.
- Shanoor Seervai, “Surprise! It's a $164,000 Bill for Your Heart Attack,” Apr. 5, 2019, in The Dose, produced by Joshua Tallman and Shanoor Seervai, podcast, MP3 audio, 22:04.
- Jack Hoadley, Kevin Lucia, and Maanasa Kona, "State Efforts to Protect Consumers from Balance Billing Continue, While Momentum Builds for Federal Action," To the Point (blog), Commonwealth Fund, Jan. 18, 2019.
- K. Lucia, J. Hoadley, and A. Williams, Balance Billing by Health Care Providers: Assessing Consumer Protections Across States, The Commonwealth Fund, June 2017.