Individuals are protected from surprise medical bills under both Michigan and federal law.
Emergency Services: In general, an out-of-network provider may not balance bill a participant, beneficiary, or enrollee (“Member”) for emergency services. When a health plan covers a Member’s emergency services, the health plan must also cover emergency services a Member receives without prior authorization, even if the emergency services are out-of-network. If the emergency services are provided out-of-network, the health plan cannot impose on the Member any cost-sharing that is more restrictive than the in-network emergency services cost sharing would be. The Member’s cost-sharing payments for these emergency services must be counted toward their in-network deductible or out-of-pocket maximums for their current plan.
Non-Emergency Services: In general, an out-of-network provider may not bill a Member for nonemergency services received at an in-network facility for more than the Member’s in-network cost-sharing amount. The non-emergency services must have been a benefit under the Member’s plan or coverage. Any of the Member’s cost-sharing payments for these services must be counted toward any in-network deductible or out-of-pocket maximums applied under the plan or coverage. These billing and cost-sharing restrictions would not apply if the provider gave the Member proper notice and consent.
Notice and Consent Exception: The balance billing restrictions for non-emergency services would not apply if the provider gave the Member a proper notice of the provider’s out-of-network status to which the Member consented. If the out-of-network provider obtained a proper notice and consent from the Member, then the out-of-network provider would not be limited to collecting the in-network cost sharing amount from the Member.
Emergency Services: In general, an out-of-network provider may not charge a Member more than the Member’s in-network coinsurance, copayment, or deductible for emergency services provided at either an in-network or out-of-network facility, so long as the Member’s health benefit plan covers the emergency services provided.
Non-Emergency Services: In general, an out-of-network provider may not charge a Member more than the Member’s in-network coinsurance, copayment, or deductible for non-emergency services provided at an in-network facility. This billing restriction applies when the Member’s plan otherwise covers the non-emergency services provided to the Member, and either the Member doesn’t have the ability or opportunity to choose an in-network provider, or the Member was not provided with proper disclosure of the provider’s out-of-network status prior to the services.
If you believe a provider has violated any balance billing restrictions, you may contact the following agencies: