Legal
No Suprises Act
Learn your rights against unexpected medical bills and how we ensure pricing transparency in covered services.
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 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 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 copayments 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 balance 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 may be out-of-network. In these cases, the most that 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
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 state law has similar protections to the federal No Surprises Act.
When Balance Billing Isn’t Allowed, You Also Have the Following Protections:
You are only responsible for paying your share of the cost (like copayments, coinsurance, and deductibles), as if the provider 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 prior authorization.
Cover emergency services provided by out-of-network providers.
Base what you owe the provider on the in-network amount, and show that in your Explanation of Benefits.
Count what you pay for emergency or out-of-network services toward your deductible and out-of-pocket limit.
You’re never required to give up your protections from balance billing.
You also aren’t required to get care out-of-network.
If You Believe You’ve Been Wrongly Billed
You may contact the Centers for Medicare and Medicaid Services at cms.gov for your rights under federal law.
California state law has similar protections to the federal No Surprises Act.
More information can be found at:
Uninsured and Self-Pay Patients
Your Right to a Good Faith Estimate
You have the right to a written estimate of your medical bill (called a Good Faith Estimate) when:
Your appointment is scheduled 3 or more days in advance, and
You will not be using insurance or do not have insurance
You may also request an estimate if one is not automatically provided.
Under the law, health care providers must give patients without insurance, or those not using insurance, an estimate of the bill for medical items and services.
What’s Included in a Good Faith Estimate?
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like:
Medical tests
Prescription drugs
Equipment
Hospital fees
Make sure your provider gives this estimate in writing at least 1 business day before your service or item.
You may also ask any provider for a Good Faith Estimate before scheduling.
Disputing a Bill
If you receive a bill that is $400 or more than your Good Faith Estimate, you can dispute it. This must be done within 120 calendar days of receiving the bill.
As a service to you, we provide a fee schedule in our Patient Informed Consent Agreement so you know the Good Faith Estimate for all services.
Make sure to save a copy or photo of your Good Faith Estimate.
If You Have Questions
Our patient account representatives can answer questions about your Good Faith Estimate and explain possible costs.
Phone: 424-239-9164
CMS Website: www.cms.gov/nosurprises
CMS Help Line: 1-800-985-3059
