Patient Billing Rights

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 should not be charged more than your plan's copayments, coinsurance, or deductible.

What is balance billing, sometimes called surprise billing?

When you see a doctor or other health care provider, you may owe 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 facility that is not in your health plan's network.

Out-of-network means providers and facilities that have not signed a contract with your health plan. 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 usually more than in-network costs for the same service, and it 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 cannot control who is involved in your care, for example during 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 they can bill you is your plan's in-network cost-sharing amount. You cannot be balance billed for these emergency services, including care you get after you are in stable condition, unless you give written consent to give up these protections.

Certain services at an in-network hospital or ambulatory surgical center. When you get care at 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, and similar services, and these providers cannot ask you to give up your protections. For other services at an in-network facility, an out-of-network provider cannot balance bill you unless you give written consent and give up your protections.

You are never required to give up your protections from balance billing, and you are never required to get out-of-network care. You can choose a provider or facility in your plan's network.

When balance billing is not allowed, you also have these protections

• You are only responsible for paying your share of the cost, such as the copayment, coinsurance, and deductible you would pay if the provider or facility were in-network. Your health plan pays any additional amount owed to out-of-network providers and facilities directly.
• Your health plan generally must cover emergency services without requiring you to get approval for the care in advance.
• Your health plan generally must cover emergency services by out-of-network providers.
• Your health plan generally must base what you owe the provider or facility on what it would pay an in-network provider or facility, and show that amount in your explanation of benefits.
• Your health plan generally must count what you pay for emergency services, or for certain out-of-network services, toward your in-network deductible and out-of-pocket limit.

California protections

California law, known as AB 72, also protects patients from surprise bills for non-emergency services received from an out-of-network provider at an in-network health facility.

If you think you have been wrongly billed

Contact the No Surprises Help Desk at 1-800-985-3059 or visit www.cms.gov/nosurprises for information about your rights under federal law. For California-specific complaints, contact the California Department of Managed Health Care Help Center at 1-888-466-2219 (www.dmhc.ca.gov) or the California Department of Insurance at 1-800-927-4357 (www.insurance.ca.gov), depending on the type of coverage you have.

Your right to a Good Faith Estimate of expected charges

Under the law, health care providers need to give patients who do not have certain types of health coverage, or who are not using their coverage, an estimate of the expected cost of their care before that care is provided.

• You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services, upon request or when you schedule those items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
• If you schedule a health care item or service at least 3 business days in advance, your provider or facility must give you a Good Faith Estimate in writing within 1 business day of scheduling. If you schedule at least 10 business days in advance, you must get it within 3 business days of scheduling. You can also ask for a Good Faith Estimate before you schedule anything, and you must get it within 3 business days of asking.
• If you receive a bill that is at least $400 more than your Good Faith Estimate from that provider or facility, you can dispute the bill.

Keep a copy of your Good Faith Estimate so you can compare it with any bill you later receive. For questions or more information, visit www.cms.gov/nosurprises or call 1-800-985-3059.

Open Payments

The federal Open Payments database is a tool the public can use to search payments that drug and device companies make to physicians and teaching hospitals. You can search it at https://openpaymentsdata.cms.gov.

Physician licensing

Medical doctors are licensed and regulated by the Medical Board of California, (800) 633-2322, www.mbc.ca.gov.