Rights and Protections From Surprise Medical Bills

When you get emergency care or are treated by a provider not in your health plan while at a hospital or outpatient office in your network, you are protected from surprise, or balance, billing under the federal No Surprises Act.

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

When you see a doctor or other healthcare provider, you may owe out-of-pocket costs, such as a copayment, coinsurance and/or a deductible. You may have other costs or have to pay the whole bill if you see a provider or visit a healthcare facility outside your health plan’s network.

Providers and facilities that haven’t signed a contract with your health plan are considered “out-of-network.” They may be allowed to bill you for the difference between what your plan has agreed to pay and the full amount billed for a service. Called “balance billing,” this amount is likely greater than in-network costs for the same service and may not count toward your health plan’s yearly out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who provides your care, such as when you have an emergency or you schedule a visit at a facility in your network but are treated by an out-of-network provider.

You are protected from out-of-network balance billing for: 

Emergency services

The most a provider or facility may bill you is for your health plan's in-network cost-sharing amount (such as copayments and coinsurance). 

Certain services at an in-network hospital or outpatient center

When you get services from an in-network hospital or outpatient center, some providers may be out-of-network. Those providers may bill you only for your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology and services from an assistant surgeon, hospitalist or intensivist.

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 protection 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.

Under the No Surprises Act:

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

Your health plan generally must:

• Cover emergency services without requiring you to get approval for services in advance (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.
• If you believe you’ve been wrongly billed, you may contact 1-800-985-3059.

• Centers for Medicare and Medicaid Services (CMS) details new protections ›
• California Department of Managed Health Care fact sheet PDF ›
• California Department of Insurance ›