YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE

MEDICAL BILLS

(OMB Control Number: 0938-1401)

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.

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 forthese post-stabilization services.

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 isyour plan’s in-network costsharing 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 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.

Colorado Bill HB19-1174 for Out-of-network Health Care Services

• Requires health insurance carriers, health care providers, and health care facilities to provide patients

covered by health benefit plans with information concerning the provision of services by out-ofnetwork providers and in-network and out-of-network facilities;

• Outlines the disclosure requirements and the claims and payment process for the provision of out-ofnetwork services;

• Requires the commissioner of insurance, the state board of health, and the director of the division of

professions and occupations in the department of regulatory agencies to promulgate rules that specify

the requirements for disclosures to consumers, including the timing, the format, and the contents and

language in the disclosures;

• Establishes the reimbursement amount for out-of-network providers that provide health care services

to covered persons at an in-network facility and for out-of-network providers or facilities that provide

emergency services to covered persons; and

• Creates a penalty for failure to comply with the payment requirements for out-of-network health care

services.

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:

o Cover emergency services without requiring you to get approval for services inadvance

(prior authorization).

o Cover emergency services by out-of-network providers.

o Base what you owe the provider or facility (cost-sharing) on what it would pay aninnetwork provider or facility and show that amount in your explanation of benefits.

o Count any amount you pay for emergency services or out-of-network servicestoward

your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact:

Colorado Department of Regulatory Agencies, Consumer Services Division for assistance 303-894-7490

/ 800-930-3745 (outside the Denver Metro area) / DORA_Insurance@state.co.us

Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-againstsurprise-billing-providers-facilities-health.pdf for more information about your rights under Federal law.

Visit https://leg.colorado.gov/bills/hb19-1174 for more information about your rights under Colorado State

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