Your Rights and Protections Against Surprise Medical Bills

 

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

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What is “Balance Billing” (sometimes called “Surprise Billing”)?

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When you see a doctor or health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, and/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 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 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.

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“Surprise billing” is an unexpected balance bill. This can happen when you cannot control who is involved in your care, for example, 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 protected from Balance Billing for:

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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, coinsurance, and deductibles). You cannot be balance billed for these emergency services. This includes services you may get after you are in stable condition unless you give written consent and give up your protections not to be balance billed for these post-stabilization services.

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Certain services at an in-network hospital or ambulatory surgical center

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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 cannot 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 cannot balance bill you, unless you give written consent and give up your protections.

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You are never required to give up your protection from balance billing. You also are not required to get care out-of-network. You can choose a provider or facility in your plan’s network.

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Additionally, under Colorado Law (applicable to Colorado-Based Health Plans only), your health care provider must refund any amount you overpay due to an impermissible balance bill within 60 days of being notified of the overpayment.

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When balance billing is not allowed, you also have the following protections:

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You are only responsible for paying your share of the cost (copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.

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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 deductible and out-of-pocket limit.

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If you believe you have been wrongly billed, please contact Gastroenterology of the Rockies at 303-604-5000.

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If we are unable to resolve your complaint, you may contact the No Surprises Helpdesk at 1 (800) 985-3059.

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Patients with Colorado-based health plans (your ID card will have “CO-DOI” printed on it) may also contact the Colorado Medical Board at (303) 894-7800 or dora_medicalboard@state.co.us.

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Visit the CMS No Surprises Act website (https://www.cms.gov/nosurprises/consumers) for more information about your rights under federal law.

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Visit Colo. Rev. Stat. § 12-30-112 for more information about your rights under state law.

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