Ohio Billing Rights

Additional State-Law Protections for Patients with State-Regulated Health Plans

• Surprise billing happens when a patient receives an unexpected bill after unanticipated care from an out-of-network health care provider, which can occur at an in-network health care facility such as a hospital, or at an out-of-network health care facility. It can happen for both emergency and non-emergency care. Typically, patients are unaware that the health care provider or health care facility is out-of-network until they receive the bill.
• Emergency Situation: An individual with insurance has an unanticipated, medical emergency event requiring “emergency services”. This individual is taken to an “out-of-network” health care facility and receives emergency care. Due to the emergency situation, the individual was unable to select an in-network health care provider. Similarly, the individual is taken to an in-network health care facility but received emergency care from out-of-network health care providers working with that health care facility. Because of the emergency, the individual was unable to select an in-network health care facility or health care provider. “Emergency services” in both in-network and out-of-network settings mean the following, according to the law:
  • Medical screening examinations to determine whether an emergency medical condition exists.
  • Treatment that is necessary to stabilize an emergency medical condition.
  • Appropriate transfers prior to an emergency medical condition stabilization.
• Non-Emergency Situation: An individual with insurance schedules an elective treatment or nonemergency care appointment with an in-network health care provider. During the scheduled visit to the health care provider’s facility, the patient receives services from an out-of-network health care provider. This could be a service from a doctor or related to imaging, laboratory services, etc. The patient, after this “unanticipated out-of-network care” then receives a surprise bill for out-of-network services received even though the treatment occurred in an in-network health care facility. For additional treatment situation examples, including about consent, go to insurance.ohio.gov/consumers/surprise-billing/resources/surprise-billing-scenarios-protections-consumers. “Unanticipated out-of-network care” mean the following, according to the law:
  • Health care services covered under a health benefit plan and provided by an out-of-network health care provider when either of the following conditions applies:
  • The covered person did not have the ability to request such services from an in-network health care provider.
  • The services provided were emergency services.
• Ground Ambulance Situation: The Ohio law also protects consumers from ground ambulance surprise billing situations.

Filing a Complaint

If you receive a surprise bill that you believe is prohibited by state or federal law, first, try to resolve the dispute yourself with your health insurer and health care provider. If the dispute remains unresolved, contact the Ohio Department of Insurance through insurance.ohio.gov, consumer.complaint@insurance.ohio.gov, or 800-686-1526 to file a complaint.

State Agency Contact Information

Ohio Department of Insurance

Phone: 800-686-1526
Website: insurance.ohio.gov

Additional Information

Visit www.cms.gov/nosurprises/consumers or call 800-985-3059 for more information about your rights under federal law.