Understanding In-Network vs. Out-of-Network Providers

• In-Network Provider: A doctor, hospital, or facility that has a contract with your health plan to provide services at pre-negotiated rates.

• Out-of-Network Provider: A provider or facility that does not have a contract with your health plan. Out-of-network care usually costs more, and you may be responsible for the difference between what your plan pays and what the provider charges (“balance billing”).

What is Balance Billing (Surprise Billing)?

When you receive care, you typically pay your share of the costs (copayments, coinsurance, deductibles). If you choose an out-of-network provider or facility, you may be responsible for the entire bill.

Balance billing occurs when an out-of-network provider bills you for the difference between what your plan pays and the full amount charged.

Surprise billing is an unexpected balance bill, often occurring when you cannot control who is involved in your care—such as during emergencies or when you receive care at an in-network facility but are treated by an out-of-network provider.

When Are You Protected from Surprise Billing?

Emergency Services

• If you receive emergency care at an out-of-network hospital or facility, you cannot be billed more than your in-network cost-sharing amount (copayments, coinsurance, deductibles).
• Your health plan must cover emergency services without requiring prior authorization, regardless of whether the provider or facility is in-network or out-of-network.
• Out-of-network providers and facilities cannot balance bill you for emergency services.

Non-Emergency Services at In-Network Facilities

• When you receive care at an in-network hospital or ambulatory surgical center, certain providers (such as anesthesiologists, radiologists, pathologists, and others) may be out-of-network.
• These out-of-network providers cannot balance bill you for covered services at an in-network facility.
• You are only responsible for your in-network cost-sharing amount.

Non-Emergency Services at Out-of-Network Facilities

• If you choose to receive non-emergency care at an out-of-network facility, you may be responsible for higher costs, including possible balance billing. You are not protected from surprise billing in this situation unless otherwise specified by law.

What Are You Responsible For?

• You are only responsible for paying your share of the cost (copayments, coinsurance, deductibles) that you would pay if the provider or facility was in-network, in situations protected by law.
• Your health plan will pay any additional costs to out-of-network providers and facilities directly, when protections apply.
• Any amount you pay for emergency services or protected out-of-network services counts toward your in-network deductible and out-of-pocket limit.

What Are Your Rights?

• You are never required to give up your protections from balance billing.
• You are not required to get care from an out-of-network provider or facility.
• You can always choose a provider or facility in your plan’s network.

What If You Think You Have Been Wrongly Billed?

• No Surprises Help Desk: Call 1-800-985-3059 for assistance and guidance.
• File a Complaint Online: Click here to visit the Centers for Medicare & Medicaid Services to submit a complaint.
• Florida Insurance Consumer Helpline: Call 1-877-693-5236 for help with insurance-related billing issues.
• More Information: For details about your rights under Florida Statute §627.64194, click here to visit the Florida Senate Statute.

Quick Reference Table

Insurer and Provider Responsibilities

• Insurers must pay out-of-network providers directly for covered emergency and certain non-emergency services.
• Payment disputes between providers and insurers cannot involve the patient.
• Providers may not collect or attempt to collect any excess amount from the patient beyond copayments, coinsurance, and deductibles.
• Insurers must reimburse nonparticipating providers according to state law timelines (generally within 30–45 days for clean claims).