Surprise Medical Billing
Your Rights and Protections Against Surprise Medical Bills
When you unknowingly receive care outside of your insurance network – such as receiving emergency care at an out-of-network facility or receiving treatment by an out-of-network provider at an in-network hospital – the laws in Colorado protect you from “surprise” or balance billing.
- Surprise billing, also called balance billing, is an unexpected bill for the difference between what your insurance plan covered and the total bill. This can happen if you receive emergency care from facilities or providers that are out-of-network, including some ambulances, or if you visit an in-network facility but are unexpectedly treated by an out-of-network provider.
- In 2019, Colorado passed a law that protects Colorado consumers with state-regulated health insurance plans from being balance billed for unknowingly receiving care outside of their insurance network. To see if your health insurance plan is state-regulated in Colorado, check for “CO-DOI” on your insurance card.
- If you receive services from an out-of-network provider at an in-network facility, you can’t be balance billed unless you have given your prior written consent.
- Consumers who knowingly seek care from an out-of-network provider or facility are responsible for all costs.
If you believe you’ve been wrongly billed for out of network charges, contact the CU Medicine billing team by email at email@example.com or call our Patient Services team at 303-493-7700.
For more information about your rights under Colorado law, visit the Colorado Department of Regulatory Agencies Division of Insurance website.
For more information about your rights under federal law, visit the Centers for Medicare & Medicaid Services website.
What Is Balance Billing?
When you see a healthcare provider, you may be responsible for paying 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 healthcare facility that isn’t in your health plan’s network.
Out-of-network refers to providers and healthcare facilities that haven’t signed a contract with your health insurance plan. Out-of-network providers may be permitted to bill you for the difference between what your health insurance 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 if you receive emergency care from facilities or providers that are out-of-network, including some ambulances, or if you visit an in-network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
If you have an emergency medical condition and receive 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.
Certain services at an in-network hospital or ambulatory surgical center
When you receive healthcare services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network for you. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to services provided by: emergency medicine, anesthesiology, pathology, radiology, laboratory, neonatology, assistant surgeons and hospitalists or intensivists. These providers cannot balance bill you and may not ask you to give up your protections not to be balance billed.
If you receive other healthcare services at these in-network facilities, out-of-network providers cannot 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.
This law applies to me. How will this impact me?
- You are only responsible for paying your share of the cost (such as the copayments, coinsurance and deductibles that you would pay if the provider or facility was in-network) required by your insurance plan. The rate you pay is based on your set in-network rate for that care. Your health plan will pay out-of-network providers and facilities directly.
- Hospitals and some other providers are required to give you a written disclosure notifying you that you have the right to ask to see an in-network provider and to be notified ahead of time, if possible, if you are receiving out-of-network care. They may ask you to sign this disclosure.
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.