No Surprises Act

Your rights and protections

When you get emergency care or are 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 under the federal No Surprises Act.

What is "balance 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 need to pay the entire bill if you see a provider or visit a 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 allowed to bill you for the difference between what your plan pays 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 cannot 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 they can bill you is your plan's in-network cost-sharing amount (such as copayments and coinsurance). You cannot 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 balance billed for those 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 can 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 out-of-network care. You can choose a provider or facility in your plan's network.

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

• You are only responsible for paying your share of the cost (like copayments, coinsurance, and deductibles that you would pay if the provider or facility were in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
• Your health plan generally must cover emergency services without prior authorization, cover emergency services by out-of-network providers, base what you owe on what it would pay an in-network provider or facility, and count any amount you pay toward your deductible and out-of-pocket limit.

If you think you've been wrongly billed

Contact Colorado Access Choice member services or visit the federal No Surprises Help Desk at cms.gov/nosurprises or call 1-800-985-3059.

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