CurrentWashington Office of the Insurance CommissionerPolicy N/A

Washington surprise billing and balance billing protections

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This document explains Washington State protections against surprise bills and balance billing for people receiving emergency care, ground/air ambulance, or care from out-of-network providers at in-network hospitals or ambulatory surgical centers. It informs patients of rights, limits on charges, and complaint resources.

Policy Summary

PayerWashington Office of the Insurance Commissioner

PolicyWashington surprise billing and balance billing protections

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionInsurers must cover emergency services without prior authorization and cover emergency services provided by out-of-network providers.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

emergency servicesEmergency services not balance-billed

in-network capIn-network facility out-of-network providers capped

no waiverProviders cannot require waiver

counts toward limitsCost-sharing counted toward limits

hotlinesComplaint hotlines listed

Balance-Billing Protections & Patient Responsibilities

Balance-billing protections and insurer/provider requirements

When balance billing is prohibited and patient responsibilities:

Emergency services from out-of-network providers or facilities: patient payment limited to the plan's in-network cost-sharing (copay/coinsurance); no balance billing allowed.

Includes ground and air ambulance services; hospital care for emergencies; and emergency behavioral health or substance use disorder emergency care. Post-stabilization services are also covered under this protection.

When receiving care at an in-network hospital or ambulatory surgical center, certain providers at that facility may be out-of-network but may only charge the patient's in-network cost-sharing amount.

When balance billing is not allowed, the patient is only responsible for their plan cost-sharing (copay, coinsurance, and deductible as applicable); the health plan must pay the out-of-network provider or facility directly.

Insurer obligations include: covering emergency services without prior authorization; covering emergency services provided by out-of-network providers; determining payment to providers/facilities based on the patient's cost-sharing and showing that amount in benefit materials; and counting amounts paid by the patient for emergency or out-of-network services toward the deductible and out-of-pocket limits.

If patients believe a bill is incorrect, they may file complaints with the federal CMS portal (https://www.cms.gov/nosurprises/consumers; 1-800-985-3059) and/or the Washington OIC (visit website or 1-800-562-6900).

Financial Responsibility & Coding Notes

Patient financial responsibility cap

Cap on patient payment for emergency servicesPatient payment limited to the plan's in-network cost-sharing amount (e.g., copay/coinsurance); no balance billing for emergency services, including ground/air ambulance and hospital emergency care.

Cap for out-of-network providers at in-network facilitiesWhen treated at an in-network hospital or ambulatory surgical center, out-of-network providers may only charge the patient's in-network cost-sharing amount.

Includes post-stabilization emergency careProtections apply to emergency services received and services provided after stabilization in emergency settings.

Prior Authorization, Coverage, and Billing Requirements for Providers

Prior Authorization

Prior authorization and emergency coverage

Insurers must cover emergency services without prior authorization and must cover emergency services provided by out-of-network providers; plans will directly pay out-of-network providers/facilities and apply payments toward the member’s deductible and out-of-pocket limits.

You do not need prior authorization for emergency services; insurers generally must cover them.
Insurers must cover emergency services provided by out-of-network providers and pay those providers/facilities directly.
Amounts you pay for emergency or out-of-network services must be counted toward your deductible and out-of-pocket maximums.

Key Terms

Balance billing / 差額帳單

DefinitionBalance billing (差額帳單): The difference between what an out-of-network provider bills and what the patient's plan agrees to pay; may exceed in-network rates and may not count toward annual out-of-pocket limits.

When it can occurOccurs if you see an out-of-network provider or facility and they bill you for the amount above what the plan pays.

Provider disclosure requirementInsurers and certain providers must list in-network providers and networks on their websites or provide them on request to help patients avoid balance bills.

Surprise bill / 意外帳單

DefinitionSurprise bill (意外帳單): An unexpected balance bill that happens when patients cannot control which providers participate in their care (e.g., ambulance transport, emergencies, or receiving care from an out-of-network provider at an in-network facility).

Common scenariosMay occur during emergency care, ambulance transport, or when scheduled care at an in-network facility includes out-of-network providers.

Patient recourseIf you believe a bill is incorrect, you may file complaints with federal CMS or Washington OIC (contact details provided in the document).

Out-of-network / 網絡外

DefinitionOut-of-network (網絡外): Providers or facilities not contracted with the patient's health plan.

Billing consequenceOut-of-network providers may bill the difference between plan payment and charges (balance bill) unless covered by specific protections such as emergency services or out-of-network care at in-network facilities.

Patient choiceYou are not required to receive out-of-network care; you may choose in-network providers or facilities when possible.

Policy Summary

PayerWashington Office of the Insurance Commissioner

PolicyWashington surprise billing and balance billing protections

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionInsurers must cover emergency services without prior authorization and cover emergency services provided by out-of-network providers.

SourceLink

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Washington surprise billing and balance billing protections

Customize your policy alerts

Sign up for all Washington Office of the Insurance Commissioner policy alerts

Know when Washington Office of the Insurance Commissioner releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Balance-Billing Protections & Patient Responsibilities

Balance-billing protections and insurer/provider requirements

When balance billing is prohibited and patient responsibilities:

Emergency services from out-of-network providers or facilities: patient payment limited to the plan's in-network cost-sharing (copay/coinsurance); no balance billing allowed.

When receiving care at an in-network hospital or ambulatory surgical center, certain providers at that facility may be out-of-network but may only charge the patient's in-network cost-sharing amount.

Financial Responsibility & Coding Notes

Patient financial responsibility cap

Includes post-stabilization emergency careProtections apply to emergency services received and services provided after stabilization in emergency settings.

Prior Authorization, Coverage, and Billing Requirements for Providers

Prior Authorization

Prior authorization and emergency coverage

You do not need prior authorization for emergency services; insurers generally must cover them.
Insurers must cover emergency services provided by out-of-network providers and pay those providers/facilities directly.
Amounts you pay for emergency or out-of-network services must be counted toward your deductible and out-of-pocket maximums.

Key Terms

Balance billing / 差額帳單

When it can occurOccurs if you see an out-of-network provider or facility and they bill you for the amount above what the plan pays.

Provider disclosure requirementInsurers and certain providers must list in-network providers and networks on their websites or provide them on request to help patients avoid balance bills.

Surprise bill / 意外帳單

Common scenariosMay occur during emergency care, ambulance transport, or when scheduled care at an in-network facility includes out-of-network providers.

Patient recourseIf you believe a bill is incorrect, you may file complaints with federal CMS or Washington OIC (contact details provided in the document).

Out-of-network / 網絡外

DefinitionOut-of-network (網絡外): Providers or facilities not contracted with the patient's health plan.

Patient choiceYou are not required to receive out-of-network care; you may choose in-network providers or facilities when possible.