No Surprise Act

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.

Both federal law and state law protect against surprise billing. The No Surprises Act provides federal protection to members. Meanwhile, California has existing law that protects members enrolled in a Health Maintenance Organization (HMO) or other CA licensed plan.

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, 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.

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 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.

CA law protects enrollees in state regulated plans from surprise medical bills when an enrollee receives emergency services from a doctor or hospital that is not contracted with the patient’s health plan or medical g oup. In covered circumstances providers cannot bill consumers more than their in‐networking cost sharing.

Certain 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.

California law protects enrollees in state regulated plans from surprise medical bills when an
enrollee receives scheduled care at an in‐network facility such as a hospital lab or imaging
center but services are delivered by an out‐of‐network provider. In covered circumstances,
providers cannot bill consumers more than their in‐network cost sharing. Further, for uninsured individuals, hospitals must provide the patient with a written estimate of the amount the hospital will require for the expected services at the time of service.

When balance billing isn’t allowed, you also have the following 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.
  • 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 1‐888‐466‐2219 for enforcement issues related to state regulated plans OR 1‐800‐985‐3059 (https://www.cms.gov/nosurprises/consumers) for enforcement issues related to federally regulated plans.

Visit www.cms.gov/nosurprises for more information about your rights under federal law.
Visit www.healthhelp.ca.gov for more information about your rights under state law.

VEBA members can go to their enrolled plan’s website for more information at:

• Cigna
• Kaiser Permanente
• UMR
• UnitedHealthcare
• While SIMNSA is a healthcare service plan in Mexico and does not abide by US Federal law, SIMNSA is required to follow California State law AB 72 language as it pertains to emergency/urgent care balance billing for services in the US.