Wisconsin provides balance billing protections to patients receiving care at in-network facilities, and federal protections also apply. Understanding these rules helps you navigate unexpected out-of-network bills and dispute them effectively.
Wisconsin Act 14 (2022) Balance Billing Protections
Wisconsin Act 14, enacted in 2022, provides some balance billing protections for patients receiving services at in-network facilities. The law aligns with the federal No Surprises Act and aims to prevent patients from bearing the cost of out-of-network provider bills.
Federal No Surprises Act as Primary Protection
The federal No Surprises Act, effective January 1, 2022, is the primary balance billing protection for Wisconsin patients. It covers emergency care at any facility and scheduled services at in-network facilities provided by out-of-network providers. Patients are responsible only for in-network cost-sharing amounts.
What Qualifies as Covered Surprise Care
Balance billing protections apply in two situations: (1) emergency services at any hospital or facility, and (2) scheduled non-emergency services at in-network facilities where an out-of-network provider is involved without the patient's knowledge.
Insurance Plan Jurisdiction
The Wisconsin Office of the Commissioner of Insurance (OCI) enforces state-regulated health plans, while the Centers for Medicare and Medicaid Services (CMS) handles ERISA self-insured plans. Knowing your plan type determines where to file a dispute.
How to Dispute a Balance Bill in Wisconsin
- Verify the service qualifies under the No Surprises Act (emergency or scheduled service at in-network facility).
- Contact your health plan citing the federal No Surprises Act and Wisconsin Act 14.
- Request an in-network rate adjustment in writing, including copies of the bill and explanation of benefits.
- File an OCI complaint if the health plan refuses to adjust the bill within 30 days.
Altair tracks balance billing claims and helps you identify coverage violations so you can enforce your rights.
Frequently Asked Questions
Does Wisconsin have its own balance billing law?
Yes, Wisconsin Act 14 (2022) provides balance billing protections. However, the federal No Surprises Act is the primary protection and often provides greater coverage than state law alone.
How do Wisconsin patients dispute an unexpected out-of-network bill?
Contact the health plan in writing, citing the No Surprises Act. If the plan is state-regulated, file a complaint with the Wisconsin OCI at oci.wi.gov. For ERISA plans, contact CMS at cms.gov/nosurprises.
Can Wisconsin patients be balance billed at in-network facilities?
No, under the No Surprises Act and Wisconsin Act 14, patients cannot be balance billed for emergency services or scheduled services at in-network facilities, even if the provider is out-of-network.
Related Wisconsin Insurance Topics
- Wisconsin Timely Filing Requirements
- Wisconsin Surprise Billing Protections
- Wisconsin Prior Authorization Rules
- All State Billing Laws
- Federal No Surprises Act