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 โbalance billingโ (sometimes called โsurprise billingโ)?
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 isnโt in your health planโs network.
โOut-of-networkโ describes providers and facilities that havenโt 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 โbalance billing.โ This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
โSurprise billingโ is an unexpected balance bill. This can happen when you canโt control who is involved in your careโlike 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:
Emergency services
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 planโs in-network cost-sharing amount (such as copayments and coinsurance). You canโt be balance billed for these emergency services. This includes services you may get after youโre in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
California state law has similar protections to the federal No Surprises Act.
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 planโs in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers canโt 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 canโt balance bill you, unless you give written consent and give up your protections.
Youโre never required to give up your protections from balance billing. You also arenโt required to get care out-of-network. You can choose a provider or facility in your planโs network.
California state law has similar protections to the federal No Surprises Act. More information can be found at California Department of Managed Care Surprise Medical Bills Fact Sheet.
When balance billing isnโt 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 bene๏ฌts.
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe youโve been wrongly billed, you may contact the Centers for Medicare and Medicaid Services at CMS at www.cms.gov for your rights under federal law.
For more information about your rights under California state law visit the California Department of Managed Health Care at www.dmhc.ca.gov or California Department of Insurance at www.insurance.ca.gov.
