Your Rights and Protections Against Surprise Medical Bills
When Prometheus is out-of-network with your insurance provider, and provides you with emergency care or laboratory services performed while you are at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s allowed copayments, coinsurance and/or deductible.
What is “balance billing” (sometimes called “surprise billing”)?
When you receive laboratory services from Prometheus, or 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 also may have other costs or have to pay the entire bill if you receive care from a provider that is “out-of-network” for your health plan or insurer.
“Out-of-network” means the provider has not signed a contract with your health plan to provide services. If Prometheus is out-of-network for your plan or insurer, it may be allowed to bill you for the difference between what your plan agreed to pay Prometheus and the full amount Prometheus charged the plan for a service. This is called “balance billing.”
“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 that you do not or cannot choose.
You are protected from balance billing for:
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 typically 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 at the facility caring for you after you’re in stable condition.
Laboratory services at an in-network hospital or ambulatory surgical center
When you get laboratory services from an in-network hospital or ambulatory surgical center, Prometheus may be out-of-network. In these cases, the most Prometheus typically may bill you is your plan’s in-network cost-sharing amount.
Effect of Specific State Rules
Some states have their own laws that may control or influence what Prometheus can bill you for out-of-network laboratory services and which may be different from those described here.
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.