Your Rights and Protections Against Surprise Medical Bills

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.

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 balanced billed for these post-stabilization services.

CO, FL, GA, IL, MI, NV, OH and TX have state laws that prohibit certain surprise medical bills when you see an out-of-network provider. If you had emergency services from an out-of-network provider you are protected under the federal law, and may also be protected under a state law. You can visit the following state websites to gain additional information on your protections under state law:

• Colorado Consumer Health Initiative – Surprise Medical Bills
• Florida Office of Insurance Regulation – Consumer Resources
• Georgia Office of the Insurance and Safety Fire Commissioner – Insurance Resources
• Illinois Department of Insurance – Consumers
• Michigan Department of Insurance and Financial Services
• Nevada Division of Insurance
• Ohio Department of Insurance – Surprise Billing
• Texas Department of Insurance – Consumer Protection

Certain non-emergency 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 there may be out-of-network. In these cases, the most those 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, 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.

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.

CO, FL, GA, MI, OH, and TX have state laws that prohibit certain surprise medical bills when you see an out-of-network provider. If you had non-emergent services from an out-of-network provider at an in-network facility you are protected under the federal law, and may also be protected under a state law. You can visit the following state websites to gain additional information on your protections under state law:

• Colorado Consumer Health Initiative – Surprise Medical Bills
• Florida Office of Insurance Regulation – Consumer Resources
• Georgia Office of the Insurance and Safety Fire Commissioner – Insurance Resources
• Michigan Department of Insurance and Financial Services
• Ohio Department of Insurance – Surprise Billing Toolkit
• Texas Department of Insurance – Consumer Protection

For Colorado residents

If you believe you've been wrongly billed, please contact your insurance company at the number on your ID card.

You can also contact the Colorado Division of Insurance at:

• 303-894-7490
• 1-800-930-3745 (outside of the Denver Metro area)
• DORA_Insurance@state.co.us

For reimbursement information, see these details about out-of-network health care provider reimbursements.

Ambulance Information: Balance billing claims related to services provided by air ambulances are governed by federal law. Services provided by ground ambulances are regulated by Colorado state law and do not allow private companies to balance bill. However, you may be balance billed for emergency services you receive if the ambulance service provider is a publicly funded fire agency or if the ambulance services are for a non-emergency, such as ambulance transport between hospitals, that is not a post-stabilization service.

• You are only responsible for paying your share of the cost (like the 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.
• 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 the No Surprises Help Desk (NSHD) at 1-800-985-3059 or www.cms.gov/nosurprises/consumers.