US · guidance
CMS Pub. 100-16, ch. 4, § 170
Balance Billing
The guidance in this section applies to HMOs (Health Maintenance Organizations),
HMOPOS (HMO Point of Service), PPOs (Preferred Provider Organizations), and
RPPOs (Regional PPOs).
When enrollees obtain plan-covered services in an HMO, PPO, or RPPO, they may not
be charged or held liable for more than plan-allowed cost-sharing. Providers who are
permitted to ‘balance bill’ must obtain the amount in excess of the enrollee’s cost-sharing (the balance) for services, directly from the MAO and not from the enrollee.
History
(Rev. 121, Issued: 04-22-16, Effective: 04-22-16, Implementation: 04-22-16)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
d006bef9e1570d59adb1d2f5bd1cab6a821e29f54daf562b21a4056816ab4886
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