Care & Costs
Questions and answers about care and costs
First, when you visit a provider, make sure that everyone who participates in your care is in your plan network, including labs or tests. Learn more about out-of-network billing in How Health Plans Work.
Your rights and protections against surprise medical bills or balance billing
As of January 1, 2020, members of individual and family plans—as well as some group plans—in Washington have the protection of the Washington Balance Billing Act. Effective January 2025, the Washington Balance Billing Protection Act was amended throughSenate Bill 5986 to include certain emergency and non-emergency ground ambulance services.
As of January 1, 2022, you also have federal rights and protections again surprise medical bills under the No Surprises Act.
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 facilitythat 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 aservice. 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 in-network facility but are unexpectedly treated by an out-of-networkprovider.
Health plans are required to tell you, via their websites or on request, which providers, hospitals and facilities are in their networks. Hospitals, surgical facilities, and providers must tell you which provider networks they participate in on theirwebsite or on request.
You are protected from balance billing for:
Emergency services
If you have a medical, mental health, or substance use disorder emergency and get emergency services from an out-of-network provider or facility, you are only responsible for your plan’s in-network cost-share amount (copay or coinsurance). If you have an emergency medical condition, mental health, or substance use disorder condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan's in-network cost-sharingamount (such as copayments and coinsurance). This includes ground or air ambulance rides and care you receive in hospitals or facilities that provide crisis services to people experiencing a mental health or substance use disorder emergency.You can’t be balance billed for these emergency services or services you may get after you’re in stable condition.
If you have coverage through a self-funded group health plan, in some limited situations, a provider can ask you to consent to waive your balance billing protections, but you are never required to give your consent.
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 toemergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, surgeons and assistant surgeons, hospitalists, or intensivist services. These providers can't balance bill you and cannot ask you to give up your protections notto 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.
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:
- Cover emergency services without requiring you to get approval for services in advance (prior authorization).
- Cover emergency services by out-of-network providers.
- 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.
- 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:
File a complaint with the federal government
By phone: 800-985-3059
Online: cms.gov/nosurprises
File a complaint with the Washington state Office of the Insurance Commissioner
By phone: 800-562-6900
Online: insurance.wa.gov/file-complaint-or-check-your-complaint-status
For more information about your rights, visit:
If you ever get a bill or claim that doesn't seem right, be sure to contact us and we'll look at it with you.
Some services and drugs require prior authorization, also known as preapproval, from your health plan before receiving care. For more information about your coverage information, sign into your account.
If you go to Find Care from your dashboard, you’ll see that the providers listed are those in your network. Note that the search is set up by ZIP code, so if you need to see a doctor in another area, change the ZIP code to that area. When you call to make the appointment, check that the provider is still taking your plan, not simply “taking Premera.” If your provider orders tests or labs, ask that they only send you to in-network facilities.
If you do not sign in, you can still use Find Care by selecting the network yourself. You can find the name of your network on the front of your member card.
Some providers require that they see a copy of your card at the time of your appointment. For members with an employer-sponsored plan, you can access your digital ID card with the Premera App. For members with an Individual or Family plan, you can access your digital ID card by signing in to your online account, or by signing up for digital health messages.
There are no limits or controls on the charges out-of-network providers can bill, so you may receive much higher bills than you expect. In-network providers contract with Premera and charge lower rates that are set for services and procedures. We call these allowed amounts.
Your plan only contributes to allowed amounts. So, if you have a procedure with an in-network provider who usually charges $200, but the allowed amount is $150, they can only charge $150. If you have the same procedure with an out-of-network provider, the provider can bill you a higher amount. If your plan pays 60 percent for out-of-network services, that’s only 60 percent of the allowed amount. The 40 percent of the allowed amount (your coinsurance) and anything over that would be your responsibility.
It depends. Some plans have no out-of-network coverage at all. Other plans have separate in-network and out-of-network deductibles and out-of-pocket maximums. Your safest bet to save money is to only use in-network providers and services. To get specifics on what your plan covers and what you’ll pay, sign in and check your benefit details.
Sometimes, yes. If your provider orders services and products including lab work, durable medical equipment (wheel chairs, orthotics, and braces), CPAP (breathing machines), referrals to specialists, radiology (x-rays, CAT scans, and MRIs), or physical therapy, be sure to request that they order from providers that are in network. The savings to you could be considerable.
You have many options, although they may differ by plan. Your doctor’s office might have an after-hours number to call and leave a message for a return call. If you aren’t sure where to go, you might start with 24-Hour NurseLine for advice. The number is on the back of your member card. You can also use other virtual care options. Before visiting urgent care, make sure the facility takes your plan and it has the equipment you may need, such as an x-ray machine.
Some plans require that you select a primary care physician (PCP) before you can start using your plan benefits. We recommend that you have a PCP in any case, who gets to know you and can guide your care if you need extra help.
An in-network provider will bill Premera on your behalf and then the provider will bill you any costs that are remaining, including deductible or coinsurance. If you see an out-of-network provider, you may submit a claim to Premera. We will process itwithin 30 days of receipt. Premera explains how a claim has been processed in the form of an explanation of benefits statement (EOB).
The EOB is not a bill. It simply explains how your plan benefits apply to that claim. It includes:
- Date you received the service
- Amount billed
- Amount covered
- Amount Premera paid
- Any balance you’re responsible for
- How much has been credited toward your deductible
You will receive a separate bill from your healthcare provider for any payment owed. We recommend comparing that bill to your EOB, and then paying the provider directly.
Sign in and go to Manage Claims. When your claim has been processed, you can generate an EOB to get the details of how the claim was billed: the amount billed and covered, the amount we paid, and any balance you’re responsible for paying the provider. You’ll also find your deductible status.
Each time you receive an EOB, review it and compare it to the provider bill.
Save paper and mail! Sign in and change your preference in your account. You can see and print your EOBs any time online.
If your healthcare provider is no longer in network, use the following worksheet to see if you can continue care with your provider at the in-network level:
PBC WA Transition of Care worksheet (PDF document)
Lab work is the most common cause of unexpected costs. If your provider is ordering labs, be sure to ask if each test (in a panel, for example) is covered; if both the lab and any processing facility are in network; and that the lab is in the same state as your provider. See also How Health Plans Work.