Surprise Medical Billing

Who does this affect?

This mainly affects patients who are uninsured or are receiving services out-of-network. “Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a healthcare provider you may owe certain out-of-pocket costs, which can include copayments, coinsurance, and/or a deductible. If you see a healthcare provider or visit a healthcare facility that is not in your insurance plans network, you may have other costs or will need to pay the entire bill.

How does balance billing affect me if I am seen out-of-network?

“Balance billing” can occur when an out-of-network provider bills you for the difference between what your plan agreed to pay and the full amount charges for services.

What is “surprise billing”?

“Surprise billing” is an unexpected balance bill that can occur when you can’t control who is involved in your care. For example, in an emergency situation a provider that is not in your provider or the facility is not in network with your insurance plan.

What should I be aware of with “surprise billing”/”balance billing”?

• You are never required to give up your protections from balance billing. You are also not required to get care out-of-network. You can choose a provider or facility in your insurance 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 rendered by an out-of-network provider. In covered circumstances, providers cannot bill consumers more than their in-network cost sharing.
• Your insurance plan generally must cover emergency services without requiring you get authorization in advance and cover emergency services by out-of-network providers.

Resources regarding your rights and protections against surprise medical bills

Visit https://www.cms.gov/nosurprises/consumers for enforcement issues related to federally regulated plans.

Visit https://www.cms.gov/nosurprises for more information about you rights under federal law.

Visit https://www.dmhc.ca.gov/?referral=healthhelp.ca.gov for more information about your rights under state law.