Provider Disclosure on Patient Protections Against Balance Billing - States

OMB Control Number: 0938-XXXX
Expiration Date: xx/xx/xxxx

Model Disclosure Notice Regarding Patient Protections Against Surprise Billing
Instructions for Providers and Facilities
(For use beginning January 1, 2022)
Section 2799B-3 of the Public Health Service Act (PHS Act) requires health care providers and
facilities to make publicly available, post on a public website of the provider or facility (if
applicable), and provide a one-page notice that includes information in clear and understandable
language on:
(1) the restrictions on providers and facilities regarding balance billing in certain
circumstances,
(2) any applicable state law protections against balance billing, and
(3) information on contacting appropriate state and federal agencies in the case that an
individual believes that a provider or facility has violated the restrictions against balance
billing.
Health care providers and facilities may, but aren’t required to, use this model notice to meet
these disclosure requirements. To use this document properly, the provider or facility should
review and complete it in a manner consistent with applicable state and federal law. HHS
considers use of this model notice in accordance with these instructions to be good faith
compliance with the disclosure requirements of section 2799B-3 of the PHS Act and 45 CFR
149.430, if all other applicable PHS Act requirements are met.
If a state develops model language for its disclosure notice that is consistent with section 2799B3 of the PHS Act, HHS will consider a provider or facility that makes good faith use of the statedeveloped model language to be compliant with the federal requirement to include information
about state law protections.
Public Disclosure Requirements
The disclosure notice must be publicly available, and (if applicable) posted on a provider’s or
facility’s public website.
-

To satisfy the public disclosure requirement, providers and facilities must prominently
display a sign with the required disclosure information in a location of the provider or
facility, such as, where individuals schedule care, check-in for appointments, or pay bills,
unless the provider doesn’t have a publicly accessible location.

-

To satisfy the separate requirement to post the disclosure on a public website, the
disclosure or a link to the disclosure must appear on a searchable homepage of the
provider’s or facility’s public website.

The contents of this document do not have the force and effect of law and are not meant to bind the public in any
way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public
regarding existing requirements under the law.

Who should get this notice
In general, providers and facilities must give the disclosure notice to individuals who are
participants, beneficiaries, or enrollees of a group health plan or group or individual health
insurance coverage offered by a health insurance issuer, including covered individuals in a health
benefits plan under the Federal Employees Health Benefits Program, and to whom they furnish
items or services, and then only if such items or services are furnished at a health care facility, or
in connection with a visit at a health care facility.
Provision of the notice
Providers and facilities must provide the notice in-person, by mail, or via email, as selected by
the individual. The disclosure notice must be limited to one-page (double-sided) and must use a
font size of 12-points or larger.
Providers and facilities must issue the disclosure notice no later than the date and time on which
they request payment from the individual (including requests for copayment or coinsurance made
at the time of a visit to the provider or facility). If the provider or facility doesn’t request
payment from the individual, the notice must be provided no later than the date on which the
provider or facility submits a claim for payment to the plan or issuer.
Language access
Use of Plain Language
Health care providers, facilities, plans, and issuers are encouraged to use plain language in the
disclosure notice and test the notice for clarity and usability when possible.
Plain language, accessibility, and language access resources:
- Plainlanguage.gov/guidelines
- Section508.gov
- LEP.gov
Compliance with Federal Civil Rights Laws
Entities that receive federal financial assistance must comply with federal civil rights laws that
prohibit discrimination. These laws include section 1557 of the Affordable Care Act, Title VI of
the Civil Rights Act of 1964, and section 504 of the Rehabilitation Act of 1973. Section 1557
and title VI require covered entities to take reasonable steps to ensure meaningful access to
individuals with limited English proficiency, which may include offering language assistance
services such as translation of written content into languages other than English.
Section 1557 and section 504 require covered entities to take appropriate steps to ensure
effective communication with individuals with disabilities, including provision of appropriate
auxiliary aids and services. Auxiliary aids and services may include interpreters, large print
materials, accessible information and communication technology, open and closed captioning,
and other aids or services for persons who are blind or have low vision, or who are deaf or hard

of hearing. Information provided through information and communication technology also must
be accessible to individuals with disabilities, unless certain exceptions apply. Providers and
facilities are reminded that the disclosure notice must comply with applicable state or federal
language-access standards.
NOTE: The information provided in these instructions is intended to be only a general summary
of technical legal standards. It is not intended to take the place of the statutes, regulations, or
formal policy guidance on which it is based. Refer to the applicable statutes, regulations, and
other interpretive materials for complete and current information.
Do not include these instructions with the disclosure notice provided to patients.
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid Office of Management and Budget (OMB)
control number. The valid OMB control number for this information collection is 0938-XXXX.
The time required to complete this information collection is estimated to average 3.5 hours per
response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning
the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.

Instructions for Group Health Plans and Health Insurance Issuers
(For use for plan years beginning on or after January 1, 2022)
Federal law requires group health plans and health insurance issuers offering group or individual
health insurance coverage to make publicly available, post on a public website of the plan or
issuer, and include on each explanation of benefits for an item or service with respect to which
the requirements under section 9816 of the Internal Revenue Code (the Code), section 716 of the
Employee Retirement Income Security Act (ERISA), and section 2799A-1 of the Public Health
Service Act (PHS Act) apply, information in plain language on:
(1) the restrictions on balance billing in certain circumstances,
(2) any applicable state law protections against balance billing,
(3) the requirements under Code section 9816, ERISA section 716, and PHS Act section
2799A-1, and
(4) information on contacting appropriate state and federal agencies in the case that an
individual believes that a provider or facility has violated the restrictions against balance
billing. 1
Plans and issuers may, but aren’t required to, use this model notice to meet these disclosure
requirements. To use this document properly, the plan or issuer should review and complete it in
a manner consistent with applicable state and federal law. The Departments of Health and
Human Services, Labor, and the Treasury (the Departments) will consider use of this model
notice in accordance with these instructions to be good faith compliance with the disclosure
requirements of section 9820(c) of the Code, section 720(c) of ERISA, and section 2799A-5(c)
of the PHS Act, if all other applicable requirements are met.
If a state develops model language for its disclosure notice that is consistent with section 9820(c)
of the Code, section 720(c) of ERISA, and section 2799A-5(c) of the PHS Act, the Departments
will consider a plan or issuer that makes good faith use of the state-developed model language to
be compliant with the federal requirement to include information about state law protections.
Language access
Use of Plain Language
Plans and issuers are encouraged to use plain language in the disclosure notice and test the notice
for clarity and usability when possible.
Plain language, accessibility, and language access resources:
- Plainlanguage.gov/guidelines
- Section508.gov
- LEP.gov
1

Section 9820(c) of the Code, section 720(c) of ERISA, and section 2799A-5(c) of the PHS Act.

Compliance with Federal Civil Rights Laws
Entities that receive federal financial assistance must comply with federal civil rights laws that
prohibit discrimination. These laws include section 1557 of the Affordable Care Act, Title VI of
the Civil Rights Act of 1964, and section 504 of the Rehabilitation Act of 1973. Section 1557
and title VI require covered entities to take reasonable steps to ensure meaningful access to
individuals with limited English proficiency, which may include offering language assistance
services such as translation of written content into languages other than English.
Section 1557 and section 504 require covered entities to take appropriate steps to ensure
effective communication with individuals with disabilities, including provision of appropriate
auxiliary aids and services. Auxiliary aids and services may include interpreters, large print
materials, accessible information and communication technology, open and closed captioning,
and other aids or services for persons who are blind or have low vision, or who are deaf or hard
of hearing. Information provided through information and communication technology also must
be accessible to individuals with disabilities, unless certain exceptions apply. Plans and issuers
are reminded that the disclosure notice must comply with applicable state or federal languageaccess standards.
NOTE: The information provided in these instructions is intended to be only a general summary
of technical legal standards. It is not intended to take the place of the statutes, regulations, or
formal policy guidance on which it is based. Refer to the applicable statutes, regulations, and
other interpretive materials for complete and current information.
Do not include these instructions with the disclosure notice provided to participants,
beneficiaries, or enrollees.
Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid Office of Management and Budget (OMB)
control number. The valid OMB control number for this information collection is 0938-XXXX.
The time required to complete this information collection is estimated to average 3.5 hours per
response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning
the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.

Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an
in-network hospital or ambulatory surgical center, you are protected from
surprise billing or balance billing.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs,
such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to
pay the entire bill if you see a provider or visit a health care facility that isn’t in your health
plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your
health plan. Out-of-network providers may be permitted to bill you for the difference between
what your plan agreed to pay and the full amount charged for a service. This is called “balance
billing.” This amount is likely more than in-network costs for the same service and might not
count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is
involved in your care—like when you have an emergency or when you schedule a visit at an innetwork facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:
Emergency services
If you have an emergency medical condition and get emergency services from an out-ofnetwork provider or facility, the most the provider or facility may bill you is your plan’s innetwork cost-sharing amount (such as copayments and coinsurance). You can’t be balance
billed for these emergency services. This includes services you may get after you’re in stable
condition, unless you give written consent and give up your protections not to be balanced
billed for these post-stabilization services.
[Insert plain language summary of any applicable state balance billing laws or requirements OR
state-developed model language as appropriate]
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain
providers there may be out-of-network. In these cases, the most those providers may bill you is
your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia,
pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist
services. These providers can’t balance bill you and may not ask you to give up your protections
not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can’t balance
bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also
aren’t required to get care out-of-network. You can choose a provider or facility
in your plan’s network.
[Insert plain language summary of any applicable state balance billing laws or requirements OR
state-developed model language regarding applicable state law requirements as appropriate]

When balance billing isn’t allowed, you also have the following
protections:
•

You are only responsible for paying your share of the cost (like the copayments,
coinsurance, and deductibles that you would pay if the provider or facility was in-network).
Your health plan will pay out-of-network providers and facilities directly.

•

Your health plan generally must:
o Cover emergency services without requiring you to get approval for services in
advance (prior authorization).
o Cover emergency services by out-of-network providers.
o Base what you owe the provider or facility (cost-sharing) on what it would pay an
in-network provider or facility and show that amount in your explanation of
benefits.
o Count any amount you pay for emergency services or out-of-network services
toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact [applicable contact information for
entity responsible for enforcing the federal and/or state balance or surprise billing protection
laws].
Visit [website] for more information about your rights under federal law.
[If applicable, insert: Visit [website] for more information about your rights under [state laws].]