Surprise Billing Disclosure

Surprise Billing -- Know your rights

Beginning January 1, 2020, Colorado state law protects you* from ‘surprise billing’, also known as ‘balance billing’ when you receive covered emergency services, other than ambulance services, from an out-of-network provider in Colorado. The law also protects you when you unintentionally receive covered services from an out-of-network provider at an in-network facility in Colorado

What is surprise/balance billing and when does it happen?

You are responsible for copayments, deductibles and/or coinsurance amounts required by your health plan. If you see a provider or go to a facility that is not in your plan’s provider network, you may have to pay additional costs associated with that care. These providers are sometimes referred to as “out-of-network”.

Out-of-network providers can often bill you the difference between what your insurer decides is the eligible charge and what the out-of-network provider bills as the total charge. This is called ‘surprise’ or ‘balance’ billing.

When you CANNOT be balance-billed:

Emergency Services
In most circumstances, the most you can be billed for emergency services is your plan’s in-network cost-sharing amounts, which are copayments, deductibles, and/or coinsurance. You cannot be balanced-billed for any other amount. This includes both the emergency facility and any providers you may see for emergency care.

Certain services at an In-Network or Out-of-Network Facility
When you receive services, which may include but are not limited to surgery, anesthesia, pathology, radiology, laboratory, hospitalist, or surgical assistant services, from an out-of-network provider while you are at an in-network or out-of-network facility, 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.

Additional Protections

  • Your insurer will pay out-of-network providers and facilities directly. Again, you are only responsible for paying your in-network cost-sharing for covered services.
  • Your insurer must count any amount you pay for emergency services or certain out-of-network services (described above) toward your in-network deductible and out-of-pocket limit.
  • Your provider, hospital, or facility must refund any amount you overpay within 60 days of being notified.
  • A provider, hospital, or outpatient surgical facility cannot ask you to limit or give up these rights.
  • You have the right to request that in-network providers provide 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.

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 do receive a bill for amounts other than your copayments, deductible, and/or coinsurance, please contact us at the number on your ID card, or the Division of Insurance at 303-894-7490 or 1-800-930-3745. 

Disclaimer

* This law does not apply to all health plans and may not apply to out-of-state out-of-network providers. Check to see if you have a “CO-DOI” on your ID card; if not, this law may not apply to your health plan