Balance Billing Explained: When It Is Allowed, When It Is Banned
What is balance billing and why does it happen?
Insurers set an allowed amount for each service. In-network providers agree to accept that amount, plus your deductible, copay, or coinsurance, as payment in full. Out-of-network providers have no such agreement, so they may bill you the remaining balance between their charge and what the plan paid.
That gap can be large, which is why balance bills are so jarring. Whether you owe it depends on the type of care, the provider, and the kind of coverage you have.
When is balance billing banned?
The federal No Surprises Act (Pub. L. 116-260) protects people with most private health plans, including employer and marketplace plans, in two main situations.
- Emergency services: out-of-network emergency providers and facilities generally cannot balance bill, and your cost sharing is generally limited to in-network levels (42 U.S.C. § 300gg-111)
- Non-emergency services by out-of-network providers at an in-network facility, such as anesthesiology, radiology, or pathology: protected unless you gave proper notice and consent under the law (42 U.S.C. § 300gg-112)
- Air ambulance services are covered by the Act
- Medicaid: providers who accept Medicaid generally may not bill you beyond the Medicaid payment and any allowed copay (42 C.F.R. § 447.15)
When can balance billing still happen?
Some situations fall outside the federal ban. Ground ambulance services are not covered by the federal No Surprises Act, though state law and your plan terms may help. The Act does not apply to Medicare, Medicaid, TRICARE, VA, or Indian Health Service coverage, which have their own rules. And if you chose an out-of-network provider for non-emergency care and signed a valid consent, the protections may not apply.
State laws may add protections beyond the federal ones, so check your state insurance regulator's website.
How can you tell if you were balance billed?
Compare the provider's bill with your EOB. The EOB lists the allowed amount, what the plan paid, and the patient responsibility. If the bill asks for more than the patient responsibility, the extra may be a balance bill.
Watch for the words balance due after insurance, or for a bill from a provider you never chose, such as an anesthesiologist at an in-network hospital.
What should you do if you receive a balance bill?
Do not pay it yet. Work through these steps, keeping notes and dates.
- Get the EOB and an itemized bill, and compare the totals
- Note whether the care was emergency care and whether the facility was in-network
- Call your insurer to ask how the claim was processed and whether protections applied
- Dispute the bill in writing with the provider, citing the situation and asking for the balance to be removed
- If you cannot resolve it, call the CMS No Surprises Help Desk at 1-800-985-3059 or contact your state insurance department
How does the letter address balance billing?
Medical Bill Dispute Pro asks whether the care was emergency and whether the provider was in-network, then flags the rules that may apply. The letter's Applicable Billing Standards and Provider Obligations sections cite those rules, and the Demand section requests a response in 10 business days.
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Frequently asked questions
Is balance billing legal?
Sometimes. It can be legal when you knowingly use an out-of-network provider for non-emergency care, or in situations outside federal protections such as ground ambulances. It is banned in several cases, including emergency care and certain out-of-network care at in-network facilities under the No Surprises Act, and generally for Medicaid patients.
Can an in-network provider balance bill me?
In-network providers generally agree in their contracts to accept the plan's allowed amount, so they should only bill you the deductible, copay, or coinsurance shown on your EOB. If an in-network provider bills more, ask them to compare the bill with the EOB and ask your insurer to confirm what you owe.
Does the No Surprises Act cover my ground ambulance ride?
No. The federal No Surprises Act covers air ambulance services but not ground ambulance services. Your state may have its own protections, and your plan terms or an appeal may help. Check your state insurance regulator, review the EOB, and consider negotiating the balance.
What is the difference between balance billing and a surprise bill?
A surprise bill is an unexpected charge, often from an out-of-network provider you did not choose. Balance billing is the specific practice of billing you the difference between the provider's charge and what insurance paid. Many surprise bills are balance bills, and the No Surprises Act targets both.
Who do I call about an illegal balance bill?
Start with your insurer and the provider's billing office, then use the CMS No Surprises Help Desk at 1-800-985-3059 for federal protections. Your state insurance department handles complaints about insurers, and the state attorney general may handle provider billing practices.
Sources and further reading
- 42 U.S.C. § 300gg-111 (emergency services)
- 42 U.S.C. § 300gg-112 (out-of-network at in-network facilities)
- CMS: No Surprises Act
- 42 C.F.R. § 447.15 (Medicaid)
Related guides
Not legal or medical advice. Medical Bill Dispute Pro is a software tool that helps you prepare billing dispute letters. It is not a law firm, does not provide legal advice, and cannot guarantee any outcome. Laws and rules change and vary by plan and state; verify important details with the sources linked above, your insurer, or a qualified professional.