Your Rights and Protections Against Surprise Medical Bills

Your rights and protection against surprise medical bills 

When you receive emergency medical care or are treated by one of our out-of-network medical providers at Rady Children's Hospital-San Diego (“Rady Children's”), you are protected by balance billing. In these cases, they should not charge you more than your plan copays, coinsurance, and/or deductible. 

What is “balance billing” (sometimes called “surprise billing”)? 

When you visit 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 have to pay the entire bill if you visit a provider or medical facility that is not part of your health plan's network. 

“Out-of-network” are providers and facilities that have not signed a contract with your health plan to provide you services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount they charge for a service. This is called “ balance billing .” This amount is likely more than the in-network cost for the same service and may not apply to your plan's deductible or annual out-of-pocket limit. 

A “surprise billing” is an unexpected balance bill. Getting a surprise bill can happen when you can't control who is involved in your medical care—like when you have an emergency or plan to visit a facility in your network, but are unexpectedly treated by an out-of-network provider. net. Surprise medical bills can run into thousands of dollars, depending on the procedure or service received. 

You are protected against balance billing by: 

Emergency services 

If you have an emergency condition and receive emergency medical services from an out-of-network provider or facility, the most you can be billed is your plan's in-network cost-sharing amount (such as copays, coinsurance, and deductibles). You cannot be balanced billed for these emergency services. This includes services you may receive after you are in stable status unless you give your written consent and waive your protection against being balance billed for these post-stabilization services. 

California law protects members of state-regulated plans from surprise medical bills when a member receives emergency services from a doctor or hospital not contracted with the patient's health plan or medical group. Under coverage circumstances, providers may not bill consumers for more than their in-network cost-sharing. 

Certain services at an in-network hospital or ambulatory surgical center 

When you receive services from an in-network hospital or ambulatory surgical center, certain providers may be out-of-network. In these cases, the most these providers can bill you is your health plan's in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, surgeon 

assistant, hospitalist, or intensivist services. These providers can not balance bill you and can not ask you to waive your protection against balance billing. 

If you receive other types of services at these in-network facilities, the out-of-network providers can not balance bill you unless you give your written consent and waive your protection. 

You are not required to waive your balance billing protection. You are also not required to get out-of-network care. Other than when you have to go to the emergency room, you generally choose the provider or facility within your plan's network. 

If you receive emergency services at Rady Children's and you are not insured, it is our policy to provide financial assistance to patients whenever possible. We will contact you to tell you about our financial aid programs. If you are admitted, we will make sure you understand your rights and financial options. 

When balance billing is not allowed, you also have these protections: 

• You are only responsible for paying part of the cost (such as copayments, coinsurance, and a deductible that you would pay if the provider or facility were in-network). Any additional costs to out-of-network providers and facilities will be paid directly by your health plan. 
• Generally, your health plan must: o Cover emergency services without requiring you to get approval for the services in advance (also known as “prior authorization”). 
• Cover emergency services from out-of-network providers. 
• Base what you owe the provider or facility (cost-sharing) on ​​what you would pay an in-network provider or facility and show the amount in your explanation of benefits. 
• Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.