Most health plans encourage enrollees to use providers in their network, usually by requiring them to pay more if they use a doctor, hospital or other provider that is not in the network. But in cases of medical emergency, treatment may not always be possible in-network. The ACA prohibits health plans from:
- Requiring enrollees to get a pre-authorization for emergency services
- Making enrollees go through extra administrative hurdles to get out-of-network emergency services covered
- Charging higher co-pays or co-insurance for out-of-network emergency services than for in-network emergency services
- Limiting coverage for out-of-network emergency care more than coverage received in-network
While the ACA limits the ability of health plans to charge you more for emergency services, it does not limit the ability of out-of-network providers to bill you for the difference between what the health plan pays for the service and the provider's charge for the service. So, even if the health plan doesn't charge a higher co-pay, the enrollee might still get a bill from an out-of-network provider for other charges that were not paid by the health plan. This is called balance billing.
The ACA does not solve this problem, but does minimize providers' incentive to balance bill. The ACA sets some minimum standards for what health plans must pay out-of-network providers. The health plan must pay the greatest of these three amounts:
- The amount it pays in-network providers
- A payment based on the same methods the plan uses to pay other out-of-network services (for example, a percentage of usual and customary fees charged by other providers in your area)
- The amount Medicare would pay for that medical service
Some states also have laws to prevent balance billing. Also, Medicaid enrollees cannot be balanced billed.