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 â€śbalance billingâ€ť (sometimes called â€śsurprise billingâ€ť)?
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 isnâ€™t in your health planâ€™s network.
â€śOut-of-networkâ€ť describes providers and facilities that havenâ€™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 â€śbalance billing.â€ť This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
â€śSurprise billingâ€ť is an unexpected balance bill. This can happen when you canâ€™t control who is involved in your careâ€”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-network provider.
You are protected from balance billing for:
If you have an emergency medical condition and get emergency services from an out-of- network provider or facility, the most the provider or facility may bill you is your planâ€™s in- network cost-sharing amount (such as copayments and coinsurance). You canâ€™t be balance billed for these emergency services. This includes services you may get after youâ€™re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
For California residents: California law also prohibits balance billing for emergency services if you are a member of a health care service plan regulated under the Knox-Keene Act.Â In addition, California Assembly Bill 72 (AB 72) prohibits an out-of-network physician from billing you for nonemergency services you receive at an in-network hospital.
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 planâ€™s in-network cost-sharing amount. This may apply to emergency medicine, anesthesia, pathology, and laboratory. These providers canâ€™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 canâ€™t balance bill you, unless you give written consent and give up your protections.
Youâ€™re never required to give up your protections from balance billing. You also arenâ€™t required to get care out-of-network. You can choose a provider or facility in your planâ€™s network.
When balance billing isnâ€™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 youâ€™ve been wrongly billed, you may contact the California Department of Managed Care (DMHC) at www.HealthHelp.ca.gov or 1-888-466-2219, or the California Department of Insurance (CDI) at http://www.insurance.ca.gov/01-consumers/101-help/index.cfm or 1-800-927-4357.
Visit https://www.cms.gov/nosurprises for more information about your rights under federal law.Â Visit the following websites for more information about your rights under Californiaâ€™s AB 72: