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. The Colorado State University Health Network does not provide emergency services, therefore this provision may not apply.
NON-EMERGENCY SERVICES AT AN IN-NETWORK OR OUT-OF-NETWORK FACILITY
- The hospital or facility must tell you if you are at an out-of-network location or at an in-network location that is using out-of-network providers. It must also tell you what types of services may be provided by any 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 not available. When this happens at the Colorado State University Health Network, the most you can be billed for covered services is your in-network cost-sharing amount (copayments, deductibles, and/or coinsurance). These providers cannot balance bill you.
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.
Under Colorado law, if you receive services from an out-of-network provider, hospital, or facility in any OTHER situation, you may still be balance billed, or you may be responsible for the entire bill. If you intentionally receive non-emergency services from an out-of-network provider or facility, you may also be balance billed.
Under federal law, 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
- Please contact the CSU Health Network Billing Department by calling 970-491-7121 or emailing csuhn_billing@colostate.edu
- You may also contact the Colorado Department of Regulatory Agencies Consumer Services Division by calling 1-800-930-3745 or emailing DORA_Insurance@state.co.us
- Please visit cms.gov/nosurprises for more information about your rights under Federal law.
- Visit colorado.gov/for-consumers for more information about your rights under Colorado law.
Be prepared to avoid balance billing
- Call your insurance company’s member benefits number or help line before making an appointment of any sort of procedure.
- Ask about your plan’s coverage and network.
- Confirm with your providers that they are in-network, and that other involved providers will also be in-network.
- Ask for explanations regarding services and procedures your provider prescribe. Make sure that you understand why each is necessary and the associated costs.
Tips on reading and understanding your medical bills
Open and review all medical bills immediately and use these questions as a guide:
- Is it a bill or an explanation of benefits? (an explanation of benefits will say “this is not a bill” somewhere visible)
- Who sent the bill?
- Is the bill the expected amount? Is your insurance plan covering their share/has their contribution to the bill been accounted for?
- Is the bill overdue? Did a law firm or debt collection company send it?
- What is the bill for? (If you are confused, call the entity billing you to ask for an explanation of the charge)
- What are the details of the bill? You are entitled to an itemized bill if you ask for it; if you are unable to get one, file a complaint with the Colorado Division of Insurance here.
- Do the billed services match the services you received?
You are still responsible for any out-of-pocket costs required by your insurance plan. The rate you pay is based on your set in-network rate for that care, you can find out what this amount is before any procedure by calling your insurance company to ensure that you aren’t overcharged.
- Review your detailed estimate.
- Call your health plan. Your plan may have better information about how much you will be asked to pay. You also can ask about what’s covered under your plan and your provider options.
- Questions about this notice? Contact the Director of Operations at the CSU Health Network at alisa.kates@colostate.edu
- Questions about your rights? Please visit this website: https://www.cms.gov/nosurprises
- Prior authorization or other care management limitations
Except in an emergency, your health plan may require prior authorization (or other limitations) for certain items and services. This means you may need your plan’s approval that it will cover an item or service before you get them. If prior authorization is required, ask your health plan about what information is necessary to get coverage.
Contact your health plan to find out how much, if any, your plan will pay and how much you may have to pay.
For a detailed list of service charges at our facility, please visit https://health.colostate.edu/wp-content/uploads/2020/05/CSUHN-Service-Charges-Summary-Spring2020_050720.pdf
