Your rights & protections against surprise medical bills

What is “balance billing” (sometimes called “surprise billing”)? When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as 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 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.” “Surprise billing” is an unexpected balance bill that can happen when you can't control who is involved in your care.

You are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most they can 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.

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

When you get services from an in-network facility, 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 services such as 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.

When balance billing isn't allowed, you also have these protections:

• 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, and base what you owe on what it would pay an in-network provider.
• Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

Good faith estimate for uninsured and self-pay patients

If you are uninsured or choose not to use your health plan for a service, you generally have the right to receive a good faith estimate of the expected charges before you receive care. Ask your provider for one in writing at least one business day before your service. If you receive a bill that is at least $400 more than your good faith estimate, you may be able to dispute it through the federal patient-provider dispute resolution process.

California protections

California law provides additional surprise-billing protections for patients enrolled in health plans regulated by the state (for example, plans overseen by the Department of Managed Health Care or the California Department of Insurance). If your plan is self-funded, federal protections under the No Surprises Act generally apply instead. Which set of rules applies depends on your specific plan. If you're not sure, contact us and we will help you figure it out.

Questions or think you've been wrongly billed?

If you believe you've been wrongly billed, contact us at info@bedrock-tpa.com.

You may also contact the federal No Surprises Help Desk at 1-800-985-3059, or visit cms.gov/nosurprises for more information about your rights under federal law.

This notice is a summary provided for informational purposes and is not legal advice. It does not modify the terms of any plan, and protections vary based on your specific plan and applicable state and federal law. This page should be reviewed by counsel before publication.