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 provideror visit a hospital or other 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 are now protected from balance billing for:

Emergency services

Effective January 1, 2022, the new federal No Surprise Act adds some important consumer protections.  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.  Under the No Surprises Act, a patient can give this  consent 72 hours in advance; however, this provision does not apply to certain specialties or providers, so consumers should seek more information if requested to give such consent.  In addition, current California law allows such consent to be given as little as 24 hours in advance; reconciling this discrepancy will require further legislative action.

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 may be out-of-network. This is particularly common with such facility-based services as

emergency medicine, anesthesia, radiology, pathology/ laboratory, neonatology, assistant surgeon, hospitalist, and intensivist services. The most those providers can bill you is your plan’s in-network cost-sharing amount.   These providers can’t balance bill you and may not ask you to waive this protection against balance billing.

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 has already provided similar protection for the large majority of California consumers insured by plans regulated by the state Department of Managed Health Care. The new federal No Surprises Act extends that protection to California consumers whose insurance plans are regulated by the California Department of Insurance or by the federal Department of Labor.

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 must pay any additional costs to out-of-network providers and facilities

• 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
  • 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
  • Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket

If you think you’ve been wrongly billed, contact the appropriate authorities.

The federal  phone number for information and complaints is: 1-800-985-3059.

For assistance at the state level, you need to identify whether your plan is regulated by the Department of Managed Health Care, the Department of Insurance, or the federal Department of Labor.

You can also contact MRD’s billing support company, Zotec Partners, for a good faith estimate at 866-598-0076, or for any other billing questions or concerns.

Visit www.cms.gov/nosurprises/consumers    for more information about your rights under federal law.

Visit https://www.insurance.ca.gov/01-consumers/110-health/60-resources/upload/AB-72-Fact-Sheet-Consumer_Protection_for_Surprise_Medical_Bills-rev2.pdf  for more information about your rights under California law