Billing Rights and No Surprises Information

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, although other state or local rules may apply.

Notice and consent

In limited nonemergency circumstances, some out-of-network providers may ask whether you want to give up certain federal balance-billing protections. You are not required to give up those protections as a condition of receiving care.

Notice and consent cannot be used for emergency services, unforeseen urgent medical needs, or specified ancillary services such as emergency medicine, anesthesiology, pathology, radiology, neonatology, assistant-surgeon, hospitalist, intensivist, and certain diagnostic services.

Do not sign a notice-and-consent form unless you understand the provider's network status, the estimate, available in-network alternatives, and the rights you would give up.

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 protections and payment rules do not apply identically to every plan. They generally do not govern Medicare, Medi-Cal, or self-funded employer plans. Federal law may apply to some commercial plans not governed by California's payment rule.

If you are unsure 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:

1. Call the Member Services number on your plan identification card.
2. Ask whether the bill was submitted correctly and whether the provider, location, and service were in network for your product.
3. Ask whether MD Senior Care has delegated responsibility for the claim or decision.
4. 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.

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.

Official billing-rights resources

• CMS: Medical bill rights
• CMS: Rights for people without insurance or who pay for care themselves
• California DMHC: No Surprises Act information