No Surprises Act – Legal Notice

Your Rights and Protections Regarding Your Medical Bill

This notice explains your rights regarding your medical bill, including protections against surprise medical bills and your right to a Good Faith Estimate if you are an uninsured or self-pay patient.

Part 1: Protections for Uninsured or Self-Pay Patients: The Right to a Good Faith Estimate

As a patient who is uninsured or who chooses not to use insurance for your care, you have the right to receive a “Good Faith Estimate” (GFE) of your expected medical costs.

Under the law, healthcare providers must provide patients who are not using insurance with a written estimate of the total expected cost of any non-emergency items or services.

This GFE will be provided to you in writing at least 1 business day before your scheduled medical service.

You can also ask our office, and any other provider you choose, for a Good Faith Estimate before you schedule a service.

Dispute Rights: If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. This dispute must be filed within 120 calendar days of receiving the bill.

Make sure to save a copy or photo of your Good Faith Estimate for your records.

Part 2: Protections from Surprise “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, deductibles and/or 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 balance 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.

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; and count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
• 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.

Part 3: For More Information

For questions about a Good Faith Estimate from our office, please call our patient account representatives at (858) 703-5643.

For more information about your rights under federal law, visit www.cms.gov/nosurprises or call 1-800-985-3059.

For more information about your rights under California state law, visit the Department of Managed Health Care at dmhc.ca.gov or the Department of Insurance at insurance.ca.gov or call 1-800-927-4357.