Billing
Your Rights and Protections Against Surprise Medical Bills
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, such as a co-payment, 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 isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’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 “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your 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.
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 plan’s in- network cost-sharing amount (such as co-payments and coinsurance). 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 laws also protect consumers from surprise medical bills and prohibit balance billing when you receive emergency services (such as a hospital, lab or imaging center), provided by an out-of-network doctor or 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 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 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 care out-of-network. You can choose a provider or facility in your plan’s network.
California law generally contains balance billing protections similar to those under the No Surprises Act (as described in this Notice), except that the balance billing prohibitions also apply to services received in additional in-network facilities, including laboratories or radiology imaging centers. California also has an independent dispute resolution process to resolve claims-related issues, including disputes with your provider pertaining to receipt of improper balance bills, which can be initiated through the California Department of Insurance (see below for contact details).
When balance billing isn’t allowed, you also have the following protections:
- You are only responsible for paying your share of the cost (like the co-payments, 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
- 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 you’ve been wrongly billed, please see the contact information below for the appropriate agency to contact.
- If you are covered by a California-regulated HMO, an Anthem Blue Cross of California PPO, or a Blue Shield of California PPO, you can contact the California Department of Managed Health Care’s Help Center at 1-888-466-2219, or file a complaint at https://dmhc.ca.gov/file-a-complaint/contact-your-health-plan.aspx
- If you are covered by a California-regulated insurance company (which includes most PPOs except those offered by Anthem Blue Cross of California and Blue Shield of California), you can contact the California Department of Insurance’s consumer help line at 1-800-927-4357, or file a complaint at https://www.insurance.ca.gov/01-consumers/101-help/index.cfm.
Visit https://www.cms.gov/nosurprises/consumers for more information about your rights under federal law.
Visit https://www.dmhc.ca.gov/Portals/0/HealthCareInCalifornia/FactSheets/fsab72.pdf or https://www.insurance.ca.gov/01-consumers/110-health/60-resources/NoSupriseBills.cfm for more information about your rights under California law.
Open Payments Data Notice
The internet website link to the Open Payments data base is: https://openpaymentsdata.cms.gov
For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.