“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 32 states have enacted laws to protect enrollees from it.
See here for the criteria used to determine which states have comprehensive or partial protections.
Source: M. Kona, et al, Center on Health Insurance Reforms, Health Policy Institute, Georgetown University. Please contact Maanasa Kona for questions about this map.
Other resources:
- Jack Hoadley and Maanasa Kona, "How States Are Using Independent Dispute Resolution to Resolve Out-of-Network Payments in Surprise Billing," To the Point (blog), Commonwealth Fund, February 27, 2020.
- Maanasa Kona, Jack Hoadley, and Katie Keith, "Addressing Surprise Billing by Setting Payment Standards for Out-of-Network Providers," To the Point (blog), Commonwealth Fund, February 27, 2020.
- Jack Hoadley, Beth Fuchs, and Kevin Lucia, "Update on Federal Surprise Billing Legislation: New Bills Contain Key Differences," To the Point (blog), Commonwealth Fund, February 20, 2020.
- 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.
The Commonwealth Fund Recommends
Publication Details
Experts
