Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.
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, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or 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-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service.
You’re 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 they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
California law protects enrollees in state regulated plans from surprise medical bills when an enrollee receives emergency services from a doctor or hospital that is not contracted with the patient’s health plan or medical group. In covered circumstances, providers cannot bill consumers more than their in-network cost sharing.
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 can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other types of 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 out-of-network care. You can choose a provider or facility in your plan’s network.
California law protects enrollees in state regulated plans from surprise medical bills when an enrollee receives scheduled care at an in-network facility such as a hospital, lab, or imaging center, but services are delivered by an out-of-network provider. In covered circumstances, providers cannot bill consumers more than their in-network cost sharing. Further, for uninsured individuals, hospitals must provide the patient with a written estimate of the amount the hospital will require for the expected services at the time of service.
When balance billing isn’t allowed, you also have these protections:
You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
Generally, your health plan must:
- Cover emergency services without requiring you to get approval for services in advance (also known as “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 in-network deductible and out-of-pocket limit.
Visit the Centers for Medicare & Medicaid Services (CMS) for more information about your rights under federal law. Visit the California Department of Managed Care for more information about your rights under state law.
Good Faith Estimate
You have the right to receive a “Good Faith Estimate” explaining how much your healthcare will cost.
Under the law, health care providers need to give patients who don’t have certain types of healthcare coverage or who are not using certain types of healthcare coverage an estimate of their bill for health care items and services before those items or services are provided.
You have the right to receive a Good Faith Estimate for the total expected cost of any healthcare items or services upon request or when scheduling such items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
If you schedule a healthcare item or service at least three business days in advance, make sure your healthcare provider or facility gives you a Good Faith Estimate in writing within one business day after scheduling. If you schedule a healthcare item or service at least 10 business days in advance, make sure your healthcare provider or facility gives you a Good Faith Estimate in writing within three business days after scheduling. You can also ask any healthcare provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the healthcare provider or facility gives you a Good Faith Estimate in writing within three business days after you ask.
If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate and the bill.