Stay informed. On January 1, 2022, a new federal law, the “No Surprises Act” (NSA), will take effect. The No Surprises Act protects consumers against surprise medical bills. To learn more about the No Surprises Act visit www.cms.gov/nosurprises/consumers.
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.
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 provider or visit a 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.
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 can 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.
Certain services at an in-network hospital or ambulatory surgical center
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.
- 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 will pay any additional costs to out-of-network providers and facilities directly.
- 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 providers.
- 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 in-network deductible and out-of-pocket limit.
If you think you’ve been wrongly billed, contact the Department of Managed Health Care at 1-888-466-2219 or the No Surprises Helpdesk at 1-800-985-3059 for information and complaints.
Pursuant to 127410 of the Health and Safety Code below is the information on the Health Consumer Alliance, an organization that will help the patient understand the billing and payment process and a list of the hospital's shoppable services.
The Health Consumer Alliance (HCA) is an independent consumer assistance program that offers free assistance over-the-phone or in-person to help people who are struggling to get or maintain health coverage and resolve problems with their health plans. HCA is able to assist you with applying for coverage such as Medi-Cal, Hospital Presumptive Eligibility, private insurance, or Covered California. You may contact HCA by telephone at (888) 804-3536 or online at http://healthconsumer.org/index.php?d=partners.
Visit the hospital’s list of Shoppable Services.
Health Consumer Alliance
The Health Consumer Alliance (HCA) is an independent consumer assistance program that offers free assistance over-the-phone or in-person to help people who are struggling to get or maintain health coverage and resolve problems with their health plans. HCA is able to assist you with applying for coverage such as Medi-Cal, Hospital Presumptive Eligibility, private insurance, or Covered California. You may contact HCA by telephone at (888) 804-3536 or online.
Department of Managed Health Care
Department of Managed Health Care (DMHC) educates consumers about their health care rights, resolves consumer complaints against health plans, helps consumers understand their coverage and assists consumers in getting timely access to appropriate health care services. The DMHC Help Center provides direct assistance in all languages to health care consumers through the Department’s website, www.HealthHelp.ca.gov, and a toll-free phone number, 1-888-466-2219.