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 for these 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 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 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.
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 in advance (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 an in-network
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 services toward your
deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact the Colorado Division of Insurance at (303)-894-7490 or 1-(800)-930-3745.
Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf for more information about your rights under Federal law.
Visit 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.