Surprise Billing Disclosure

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.

If you have a “CO_DOI” on your health insurance ID card and you are receiving care and services provided at a regulated facility or agency in Colorado you can only be billed for your plan’s in-network cost-sharing amounts, which are copayments, deductibles, and/or coinsurance. You cannot be billed for anything else. This applies only to services related to and billed as an “emergency service”.

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.

If you have a “CO_DOI” on your health insurance ID card and you are receiving care and services provided at a regulated facility or agency in Colorado:

Non-Emergency Services at an In-Network or Out-of-Network Facility

Facility or agency staff must tell you if you are at an out-of-network location or if they are using out-of-network providers when known. Staff must also tell you what types of services you will be using that might be provided by an out-of-network provider.

You have the right to request that in-network providers perform all covered medical services. However, you may have to receive medical services from an out-of-network provider if an in-network provider is unavailable. If your insurer covers the service, you can only be billed for your in-network cost-sharing amount, which are copayments, deductibles, and/or coinsurance.

Additional Protections

• Your insurer will pay out-of-network providers and facilities directly.

• The provider or facility or agency must refund any amount you overpay within 60 days of being notified.

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 800.985.3059 regarding federal regulations, the Colorado Division of Insurance at 303.894.7490 or 1.800.930.3745 regarding Colorado regulations, or Linda Stilling at 720.815.4448 for agency billing.

You may also visit cms.gov/nosurprises/consumers for more information about your rights under federal law, or https://doi.colorado.gov/insurance-products/health-insurance/health-insurance-initiatives/out-of-network-health-care for more information about your rights under Colorado law.