Scope of this page
This page provides general information about selected federal and California billing protections. The rule that applies depends on your coverage, plan product, provider, facility, service, network status, and date of care.
This page does not decide whether a service is covered, whether a provider is in network, or whether a bill qualifies for a dispute. Applicable law and the governing plan documents control.
Keep copies of bills, Good Faith Estimates, Explanations of Benefits, notices, consent forms, and call-reference numbers.
When federal surprise-billing protections generally apply
For most commercial group and individual health coverage, including Federal Employees Health Benefits coverage, federal law generally protects a patient from balance billing for:
- covered emergency services provided by an out-of-network provider or facility;
- certain covered nonemergency services provided by an out-of-network provider during a visit to an in-network hospital, hospital outpatient department, critical access hospital, or ambulatory surgical center; and
- covered air-ambulance services provided by an out-of-network air-ambulance provider.
When these protections apply, the patient generally owes no more than applicable in-network cost sharing. The protected provider or facility generally may not bill the difference between its charge and the amount paid by the plan.
Federal surprise-billing protections generally do not apply to ground ambulance services; California has additional protections described below. For nonemergency care, the federal facility-based protections do not automatically apply to a routine visit at an independent physician's office or an out-of-network facility. Other laws and plan requirements may still provide protections.
Notice and consent
In limited circumstances, an out-of-network provider may ask you to waive certain federal balance-billing protections for eligible nonemergency care. A narrow exception can also apply to care after an emergency condition has been stabilized, only when the required medical, notice, consent, and applicable state-law conditions are met.
You choose whether to sign. Declining does not waive your protections, but an eligible out-of-network provider may decline the nonemergency or post-stabilization services described in the notice. You may need an in-network alternative. Emergency screening and treatment needed to stabilize you cannot be conditioned on signing away these protections.
The exception is unavailable for specified ancillary services, unforeseen urgent medical needs, and covered nonemergency services when no in-network provider at the facility can provide them. Certain protections under California law also cannot be waived through a federal form. Read the form, ask about costs and alternatives, and contact your plan or regulator if you are unsure.
California protections
For many California-regulated commercial health-plan and insurance products, state law generally limits a patient to in-network cost sharing for covered nonemergency services received from a noncontracting individual health professional at a qualifying contracting facility. California law also separately protects patients from specified emergency balance bills.
California also limits charges for covered ground ambulance services from a noncontracting provider under qualifying California-regulated commercial plans and insurance policies issued, amended, or renewed on or after January 1, 2024. When this protection applies, the patient owes no more than the applicable in-network cost sharing, and the ambulance provider cannot collect the remaining balance from the patient. Ask your plan to confirm whether your coverage is state-regulated and how the claim was processed.
The California commercial-plan protections described here do not apply identically to self-funded employer coverage, Medicare, Medicare Advantage, or Medi-Cal. Those programs have their own billing requirements and protections. If you do not know which regulator oversees your plan, call the number on your health-plan identification card.
Medicare and Medicare Advantage members
The commercial No Surprises Act protections described above do not determine Medicare, including Medicare Advantage, Medicaid, CHIP, TRICARE, Indian Health Service, or VA cost sharing. Those programs have separate rules and complaint or appeal processes.
If you are enrolled in Medicare Advantage:
- Call the Member Services number on your plan identification card.
- Ask whether the bill was submitted correctly and whether the provider, location, and service were in network for your product.
- Ask whether MD Senior Care has delegated responsibility for the claim or decision.
- Use the organization-determination, grievance, or appeal instructions in your plan's written notice or Evidence of Coverage.
Do not ignore a bill or notice containing a deadline. Contacting MD Senior Care does not extend a plan, Medicare, grievance, appeal, dispute, or court deadline.
Good Faith Estimates for uninsured and self-pay patients
If you are uninsured or qualify as self-pay for a scheduled item or service, you generally have the right to receive a written Good Faith Estimate of expected charges.
- If care is scheduled 3 to 9 business days in advance, the estimate is generally due within 1 business day after scheduling.
- If care is scheduled at least 10 business days in advance, the estimate is generally due within 3 business days after scheduling.
- If you request an estimate before scheduling, it is generally due within 3 business days after the request.
Under current federal implementation, you may need a separate estimate from each provider or facility involved in your care.
Enrollment in Medicare, including Medicare Advantage, Medicaid, CHIP, TRICARE, or a VA program does not become self-pay status for this rule merely because you choose not to submit a claim.
How to request an estimate
Ask the provider or facility that schedules the service. To ask whether MD Senior Care is responsible for the estimate, call (844) 213-8836.
If a bill is at least $400 above an estimate
An uninsured or self-pay patient may be eligible for the federal Patient-Provider Dispute Resolution process when a provider or facility's bill is at least $400 more than that provider or facility's Good Faith Estimate.
This patient process is separate from disputes between providers and health plans.
A patient dispute generally must be started within 120 calendar days after receiving the initial bill. Review current eligibility, filing instructions, and fees on the official CMS page before submitting.
CMS: Dispute a bill that is higher than your Good Faith Estimate
Complaints and help
For general Medicare information, visit Medicare.gov or call 1-800-MEDICARE.