Your Rights and Protections Against Surprise Medical Bills
When you receive emergency care or certain services from an out-of-network provider at an in-network hospital or ambulatory surgical center, federal law may protect you from balance billing, sometimes called surprise billing.
In these situations, you generally should not be charged more than your health plan's applicable in-network copayment, coinsurance, and deductible amounts.
What Is Balance Billing or Surprise Billing?
When you see a doctor or another healthcare provider, you may be responsible for certain out-of-pocket costs, including a copayment, coinsurance, or deductible.
If you receive care from a healthcare provider or facility that is not part of your health plan's network, you may have additional costs.
An out-of-network provider or facility is a provider or facility that does not have a contract with your health plan to provide services at negotiated rates.
In some circumstances, an out-of-network provider may charge you the difference between the provider's billed amount and the amount your health plan pays. This is known as balance billing.
A surprise medical bill is an unexpected balance bill. This can occur when you do not have control over all of the healthcare professionals involved in your care, such as during an emergency or when an out-of-network healthcare professional provides certain services at an in-network facility.
Federal and California laws provide protections from balance billing in certain circumstances.
You Are Protected From Balance Billing for Certain Emergency Services
If you have an emergency medical condition and receive covered emergency services from an out-of-network provider or facility, federal law generally limits the amount you can be required to pay to your health plan's in-network cost-sharing amount.
This may include your applicable:
- Copayment
- Coinsurance
- Deductible
You generally cannot be balance billed for covered emergency services protected by federal law.
These protections may also apply to certain services you receive after your medical condition has been stabilized. In limited circumstances allowed by law, different rules may apply if you voluntarily provide written consent to receive certain out-of-network post-stabilization services.
Certain Services at an In-Network Hospital or Ambulatory Surgical Center
When you receive care at an in-network hospital or ambulatory surgical center, some healthcare professionals involved in your care may be out of network.
Federal law generally protects you from balance billing for certain services provided by these out-of-network professionals.
These protections apply to certain services including:
- Emergency medicine
- Anesthesiology
- Pathology
- Radiology
- Laboratory services
- Neonatology
- Assistant surgeon services
- Hospitalist services
- Intensivist services
For services protected by the No Surprises Act, the most an out-of-network provider generally may require you to pay is your health plan's applicable in-network cost-sharing amount.
Providers of certain ancillary services generally cannot ask you to waive these federal protections.
For some other out-of-network services provided at an in-network facility, a provider may be able to bill you differently only when the requirements of federal and state law are satisfied and you knowingly and voluntarily provide any consent permitted by law.
You Are Never Required to Give Up Applicable Balance-Billing Protections
You are not required to waive protections provided to you under federal or California law.
When you have a choice of providers or facilities, you may choose a provider or facility that participates in your health plan's network.
Before receiving non-emergency services, you may wish to contact your health plan directly to confirm:
- Whether the physician is in network
- Whether the surgical or healthcare facility is in network
- Whether anesthesia, pathology, laboratory, imaging, or other professionals involved in your care are in network
- Your expected copayment, coinsurance, deductible, or other financial responsibility
California Protections Against Surprise Medical Bills
California law provides additional protections against certain surprise medical bills.
In general, California patients with applicable health coverage who receive covered non-emergency services at an in-network healthcare facility are protected when an out-of-network healthcare professional provides services without the patient's informed choice.
When California's protections apply, you generally cannot be required to pay more than the applicable in-network cost-sharing amount.
California also provides protections related to emergency services. Depending on your health plan and the services you receive, additional state protections may apply.
Certain circumstances involving a patient's voluntary choice to use an out-of-network healthcare professional may be treated differently. Specific notice, consent, timing, and cost-estimate requirements may apply before an out-of-network provider may collect applicable out-of-network cost sharing.
Because health plans are regulated by different California agencies, your rights and the agency responsible for assisting you may depend on your particular health insurance plan.
When Balance Billing Is Not Allowed, You Have Additional Protections
When federal balance-billing protections apply:
You are generally responsible only for your normal in-network cost sharing.
This may include the copayment, coinsurance, or deductible you would ordinarily pay if the provider or service were in network.
Your health plan generally must:
- Cover qualifying emergency services without requiring prior authorization.
- Cover qualifying emergency services provided by an out-of-network provider or facility.
- Calculate your applicable cost sharing using the rules required by federal law.
- Show the applicable cost-sharing amount on your Explanation of Benefits.
- Count qualifying amounts you pay toward your applicable in-network deductible and out-of-pocket maximum.
Elective and Cosmetic Services
Many cosmetic procedures are elective and may not be covered by health insurance.
The No Surprises Act does not mean that all elective, cosmetic, self-pay, or out-of-network services must be provided at an in-network price.
When a procedure is not covered by your insurance, or when you knowingly choose services that are outside your health plan's network and applicable balance-billing protections do not apply, you may be responsible for the agreed-upon cost of those services.
Chernoff Cosmetic Surgery encourages patients to ask questions about anticipated charges before treatment.
Uninsured and Self-Pay Patients
Patients who do not have insurance or who choose not to use insurance for their care may have additional rights under the No Surprises Act.
In many circumstances, uninsured or self-pay patients are entitled to receive a Good Faith Estimate explaining the expected cost of scheduled healthcare services.
If the final bill is substantially higher than the Good Faith Estimate, you may qualify to use the federal patient-provider dispute resolution process.
Please ask Chernoff Cosmetic Surgery for information about Good Faith Estimates when scheduling self-pay services.
If You Believe You Have Been Wrongly Billed
If you believe you received a bill that violates federal surprise-billing protections, you may contact the No Surprises Help Desk at:
1-800-985-3059
Additional information regarding your federal rights is available through the Centers for Medicare & Medicaid Services at:
California Department of Managed Health Care
Many California health plans are regulated by the California Department of Managed Health Care.
If you believe you have been improperly balance billed, you should first contact your health plan. You may also contact the DMHC Help Center:
1-888-466-2219
California Department of Insurance
Certain health insurance policies are regulated by the California Department of Insurance.
For questions, assistance, or complaints, contact:
Consumer Hotline: 1-800-927-4357 (HELP)
TTY: 1-800-482-4833
If you are unsure which California agency regulates your health plan, your insurance card, Evidence of Coverage, or health insurer can generally provide that information.
Questions About Your Bill or Estimated Costs
If you have questions about charges from Chernoff Cosmetic Surgery, expected costs, insurance participation, or your financial responsibility, please contact our office before your procedure.
Chernoff Cosmetic Surgery
Santa Rosa, California
Tel: 707-544-3232
Email: office@chernoffcosmeticsurgery.com
Our team will be happy to explain information available regarding anticipated charges. Questions concerning your insurance benefits, network status, deductibles, coinsurance, or coverage should also be directed to your health insurance company.
Important Notice
This notice provides general information regarding protections available under the federal No Surprises Act and applicable California law. Individual rights may vary depending on the healthcare service provided, the location where care is provided, your insurance coverage, network status, and other circumstances.
This notice does not modify the terms of your health insurance plan and is not intended as legal advice.