Quick answer: Use providers in your plan's network, check whether a service needs prior authorization, and know that an explanation of benefits (EOB) is not a bill. In a true emergency, go to the nearest hospital. For urgent but non-emergency care, an urgent care clinic may fit. Federal law protects most insured people from many surprise bills.
What does in-network mean and how do I check?
A network is the set of facilities, providers and suppliers your insurer has contracted with, per HealthCare.gov. In-network care usually costs less. To check, search your exact plan's provider directory and confirm by phone. CMS says insurers must verify directories at least every 90 days, and that if wrong directory information sends you out-of-network you may not be charged more than in-network cost sharing. Write down who confirmed and when.
How do the key terms translate?
| English term | Plain meaning | French gloss |
|---|---|---|
| Premium | Monthly payment | prime, cotisation mensuelle |
| Deductible | Amount you pay before the plan pays | franchise |
| Copay | Fixed fee per service | forfait fixe (copay) |
| Coinsurance | Percentage you pay after the deductible | quote-part, coassurance |
| Allowed amount | Maximum the plan pays for a covered service | montant autorisé (tarif négocié) |
| In-network / out-of-network | Provider has / has no contract with your plan | dans le réseau / hors réseau |
| Primary care provider (PCP) | Your main doctor | médecin traitant (proche, pas identique) |
| Referral | Written order to see a specialist | lettre d'adressage, referral |
| Prior authorization | Insurer's approval before some services | autorisation préalable, accord préalable |
| Balance billing | Provider bills you the gap over the allowed amount | facturation du solde |
| EOB (Explanation of Benefits) | Insurer's statement of how a claim was processed | relevé de remboursement (ce n'est pas une facture) |
| Appeal | Request to review a denial | recours |
Urgent care vs ER: which one should I use?
Use the emergency room for a true emergency and urgent care for an issue serious enough to see someone right away but not severe enough for the ER. HealthCare.gov defines urgent care as care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe it requires emergency room care. In a true emergency, go straight to the nearest hospital that can help; the hospital will treat you regardless of insurance. This is general information and not medical advice. If you think it is an emergency, call 911.
| Urgent care | Emergency room (ER) | |
|---|---|---|
| For | Serious enough to see right away, not an emergency | A true emergency |
| Prior approval needed? | Check your plan | No; insurers cannot require prior approval for ER care (HealthCare.gov) |
| Out-of-network | Check your plan's network | Insurers cannot charge you more copayment or coinsurance than in-network (HealthCare.gov) |
| Surprise-billing law | Only if licensed as an independent freestanding emergency department (CMS) | Applies to hospital EDs and independent freestanding EDs (CMS) |
What is balance billing and a surprise bill?
Balance billing is when a provider bills you for the difference between the provider's charge and your plan's allowed amount. HealthCare.gov's example: a $100 charge with a $70 allowed amount lets the provider bill $30, and a preferred provider may not balance bill you for covered services. A surprise bill is an unexpected out-of-network bill, often after emergency care or from a provider you did not choose at an in-network facility.
What does the No Surprises Act protect?
For people with employer, Marketplace or individual plans, it prohibits surprise bills for most emergency services, including post-stabilization services, even when the hospital is out-of-network, per CMS. It also bars out-of-network charges from out-of-network providers at certain in-network facilities, unless you gave consent as permitted by law. Your cost sharing cannot exceed in-network amounts. Ground ambulance services are not covered, per CMS. Uninsured patients can ask for a good faith estimate, and a bill $400 or more above it can be disputed.
When does the No Surprises Act not protect me?
It does not apply to Medicare, Medicaid or CHIP coverage, which have their own rules, or to short-term limited-duration insurance, health care sharing ministries, hospital indemnity, accident-only and disease-specific policies (CMS). It also does not usually apply to a non-emergency visit to an out-of-network facility or to a clinic or doctor's office that is not one of the listed in-network settings. Urgent care centers are protected only if licensed as independent freestanding emergency departments. State law may add protection.
What is prior authorization?
Prior authorization, also called prior approval or precertification, is your insurer's decision that a service, treatment, drug or equipment is medically necessary. Your plan may require it before some services, except in an emergency. HealthCare.gov warns that it is not a promise the plan will cover the cost. Ask your doctor's office to request it, and keep the approval number and date in writing.
What is an EOB and is it a bill?
An EOB is a statement from your health plan, and CMS states it is not a bill. It shows the provider's charges, allowed charges, what the plan paid and what you owe (patient balance). A separate bill comes from the provider. Compare the bill with your EOB before you pay. If the bill is higher than the patient balance, talk to the provider, then your insurer.
What should I do if I get a bill I do not understand?
- Wait for your EOB and compare amounts.
- Ask the provider for an itemized bill.
- Call your insurer and ask whether the claim was processed in-network.
- If you think you were billed wrongly for an emergency or at an in-network hospital, contact the No Surprises Help Desk at 1-800-985-3059, which CMS says offers help in many languages, including French.
- If your insurer refuses to pay a claim, you have the right to appeal and have it reviewed by a third party (HealthCare.gov).
Ask us about our Pro Help bill-review service.
Key facts
- ER care cannot require prior approval or higher copay/coinsurance for out-of-network hospitals (HealthCare.gov).
- No Surprises Act: most emergency services and some non-emergency services at in-network facilities are protected (CMS).
- An EOB is not a bill (CMS).
- No Surprises Help Desk: 1-800-985-3059 (CMS).
Frequently asked questions
What is the difference between Emergency Room and Urgent Care?
The ER is for true emergencies; urgent care is for problems needing prompt care that are not emergencies (HealthCare.gov). If in doubt and it seems an emergency, call 911.
What happens if I go to the ER without insurance?
The hospital treats emergencies whether or not you have insurance (HealthCare.gov), but you can still get a bill. Ask about payment options and financial assistance.
Does the No Surprises Act apply to urgent care centers?
Only to urgent care centers licensed as independent freestanding emergency departments, according to CMS.
Does it matter whether I go to an in-network or out-of-network ER?
For emergencies, your plan cannot charge more copay or coinsurance for an out-of-network ER, but you can still owe your deductible (HealthCare.gov).
What does in-network vs out-of-network mean?
In-network providers have a contract with your plan; out-of-network providers do not, and cost more or are not covered outside emergencies.
How do I fight balance billing?
Check your EOB, ask for an itemized bill, ask your insurer to re-process, and contact the No Surprises Help Desk if the No Surprises Act may apply.
Sources
- HealthCare.gov, getting emergency care: https://www.healthcare.gov/using-marketplace-coverage/getting-emergency-care/
- HealthCare.gov glossary, urgent care: https://www.healthcare.gov/glossary/urgent-care/
- HealthCare.gov glossary, network: https://www.healthcare.gov/glossary/network/
- HealthCare.gov glossary, balance billing: https://www.healthcare.gov/glossary/balance-billing/
- HealthCare.gov glossary, preauthorization: https://www.healthcare.gov/glossary/preauthorization/
- HealthCare.gov glossary, referral: https://www.healthcare.gov/glossary/referral/
- HealthCare.gov glossary, primary care provider: https://www.healthcare.gov/glossary/primary-care-provider/
- HealthCare.gov glossary, appeal: https://www.healthcare.gov/glossary/appeal/
- HealthCare.gov glossary, allowed amount: https://www.healthcare.gov/glossary/allowed-amount/
- CMS, No Surprises Act fact sheet: https://www.cms.gov/newsroom/fact-sheets/no-surprises-understand-your-rights-against-surprise-medical-bills
- CMS, No Surprises Act key consumer protections (PDF): https://www.cms.gov/files/document/nsa-keyprotections.pdf
- CMS, how to read an explanation of benefits: https://www.cms.gov/initiatives/your-patient-rights/medical-bill-rights/get-help/medical-bill-guides-resources/how-read-health-insurance-explanation-benefits
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Want help comparing your options in English or French? Request a quote or message Charlyne on WhatsApp. This article is general information, not personal advice; plans, prices and eligibility vary by state, insurer, immigration status and year.