Your rights and protections against surprise medical bills.

When you get emergency care or are 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 other health care provider, you may owe certain out-of-pocket costs, such as a 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. Your health insurance plan is required to tell you, on their website or at your request, which providers, hospitals and facilities are in their networks. Hospitals, surgical facilities and providers must tell you which provider networks they participate in on their website or on request. It is always a good idea to check to make sure the doctor and facility you wish to receive care at is part of your health plan’s network before scheduling.

“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 “surprise” balance billing for:

Emergency services

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 copayments and coinsurance). 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 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 those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, 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’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network. Be sure to check with your plan before seeking care within your control.

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:

  • 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 an in-network provider or facility and show that amount in your explanation of benefits.
  • 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’ve been wrongly billed by Women’s Healthcare Associates, you may contact:

Women’s Healthcare Associates, LLC
Federal Government
  • Website: www.cms.gov/nosurprises/consumers
  • Phone: 1-800-985-3059
Oregon Division of Financial Regulations
  • Website: dfr.oregon.gov/insure/Pages/index.aspx
  • Email: [email protected]
  • Phone: 1-888-877-4894

Visit www.cms.gov/nosurprises for more information about your rights under federal law.

Surprise Billing Protection Notification

Billing Terms You Should Know

  • 1 Co-pay

    Co-pay

    A co-pay is a set fee your insurance company requires you to pay for medical visits, typically ranging from $10 to $50. WHA is considered a specialist practice, but some insurance plans charge only a primary care co-pay for visits like women’s wellness exams. If you pay a primary care co-pay when a specialist co-pay is required, you may receive a bill for the difference.

  • 2 Co-insurance

    Co-insurance

    Co-insurance is the percentage of a medical bill you pay after meeting your deductible. This continues until you reach your plan’s out-of-pocket maximum. The exact amount depends on your insurance plan. If you have questions about what your insurance covers and why, contact your insurer. If you have questions about your bill from us, WHA’s financial counselors are happy to help.

  • 3 Deductible

    Deductible

    A deductible is the amount you must pay out-of-pocket before your insurance starts covering costs. Even after meeting your deductible, you may still owe a portion of your bill due to co-insurance or other cost-sharing rules. If you have questions about how your deductible applies to your care, your insurance company can provide a detailed explanation.

  • 4 Out-of-network

    Out-of-network

    If a provider or service is out-of-network, it means they don’t have a contract with your insurance company. This can lead to higher out-of-pocket costs or unexpected bills. Before your visit, it’s a good idea to check with your insurance plan to understand coverage and ask our office if we’re in-network.

  • 5 Balance billing

    Balance billing

    Balance billing happens when an out-of-network provider bills you for the difference between what your insurance pays and the total service cost. This charge is often higher than in-network costs and may not count toward your out-of-pocket limit.

  • 6 Surprise billing

    Surprise billing

    Surprise billing is an unexpected balance bill. It usually happens when you unknowingly receive care from an out-of-network provider—often at a hospital or during an emergency—and are billed for the difference between what your insurance covers and what the provider charges. In these situations, you are protected against surprise billing.

Check Accepted
Insurance

If you’re pregnant and want to begin care at WHA–or need to schedule an appointment during your pregnancy, call us! Find a provider and location here.

Please have your insurance information handy before you begin scheduling.

This will allow our teams to check whether your plan may require a referral for the care you need or to prepare benefits information to share with you at your visit. If you do not enter insurance information when scheduling, you may be asked to pay a $200-$500 deposit before receiving service.