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Surprise Billing – Know your rights

As of January 1, 2021, Georgia state law protects you from ‘surprise billing’, also known as ‘balance billing’, when you receive certain services from an out-of-network provider in Georgia.*

The law does not change what out-of-network services your plan covers. It prohibits the providers from charging you more than what your plan covers for certain out-of-network services described below.

What is surprise/balance billing and when does it happen?

You are responsible for copayments, deductibles and/or coinsurance amounts required by your health plan. If you see a provider or go to a facility that is not in your plan’s provider network, these providers are sometimes referred to as “out-of-network” and you will have to pay costs associated with that care.

When out-of-network providers bill you the difference between what your health plan issuer decides is the eligible charge and what the out-of-network provider bills as the total charge, this is called ‘surprise’ or ‘balance’ billing.

When you CANNOT be balance-billed by out-of-network providers

Out-of-Network Emergency Services in Georgia
In most circumstances, the most you can be billed for emergency services is your plan’s in-network cost-sharing amounts, which are copayments, deductibles, and/or coinsurance. You cannot be balanced-billed for any other amount. This includes both the emergency facility and any providers you may see for emergency care.

Certain Non-emergency services at an In-Network Facility in Georgia
Sometimes you might receive services such as (but not limited to) surgery, anesthesia, pathology, radiology, laboratory, hospitalist, or surgical assistant services, from an out-of-network provider while you are at an in-network facility. If you didn’t consent to receive these services from an out-of-network provider, the most you can be billed for covered services is your in-network cost-sharing amount (copayments, deductibles, and/or coinsurance). These providers cannot balance bill you.

Additional Protections

  • Your health plan issuer will pay out-of-network providers and facilities directly. Again, you are only responsible for paying your in-network cost-sharing for covered services.
  • Your health plan issuer must count any amount you pay for emergency services or certain out-of-network non-emergency services (described above) toward your in-network deductible and out-of-pocket maximum.
  • You have the right to request that in-network providers provide all covered medical services. However, you may have to receive medical services from an out-of-network provider if an in-network provider is not available.
  • The provision of covered benefits from a participating provider will not be restricted or denied solely because you obtained treatment from a nonparticipating provider leading to a balance bill. 

When you MAY be balance-billed

It’s possible you could be balance-billed when you:

  • receive services from an out-of-network provider, hospital, or facility in a non-emergency situation not described above, depending on your plan;  or
  • consent to receive services from an out-of-network provider;  or
  • receive out-of-network ground ambulance services.

In the cases above, you might be balance billed, or you might be responsible for the entire bill depending on your health plan’s coverage of out-of-network services. Care received from providers outside of Georgia is not subject to this law, and those providers may balance bill you.

If you have questions about your coverage, just call the Member Services/Customer Service number on your Kaiser Permanente ID card.

* This law does not apply to Medicare or Medicaid plans; certain group plans that are self-funded by a private employer; or the Federal Employees Health Benefits (FEHB) Program. It does not apply to out-of-state out-of-network providers.