When getting emergency care or treatment from an out-of-network provider at an in-network hospital or ambulatory surgical center, the No Surprises Act – a federal law that took effect at the beginning of 2022 – protects you from balance billing and surprise billing.
Understanding balance billing and surprise billing
When you see a doctor or other health care provider, you may have certain out-of-pocket costs, including a copayment, coinsurance or deductible. You may have other costs or need to pay the entire bill if you see a provider or visit a facility that isn't in your health plan's network.
Out-of-network providers and facilities are those that haven't signed a contract with your health plan. Balance billing occurs when out-of-network providers or facilities bill you for the difference between what your plan agreed to pay and the full amount they charge for a service. This payment might not count toward your annual out-of-pocket limit. Surprise billing is when you receive an unexpected balance bill.
Balance billing and surprise billing can happen when you can't control who is involved in your care – such as when you need emergency services or schedule a visit at an in-network facility but unexpectedly receive treatment from an out-of-network provider.
You are protected from balance billing for emergency services as well as for certain services at an in-network hospital or ambulatory surgical center.
If you have an emergency medical condition and receive emergency care 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 a copayment or coinsurance). You cannot be balance billed for emergency services. This includes care you get after your condition stabilizes, unless you provide written consent giving up your protections against being balanced billed for post-stabilization services.
Certain services at an in-network health care facility
When you get services from an in-network hospital or ambulatory surgical center, some members of your care team may be out-of-network providers. In these cases, the most those providers can bill is your plan's in-network cost-sharing amount. This applies to providers in emergency medicine, anesthesia, pathology, radiology, laboratory services, neonatology, assistant surgeon services, and hospitalist or intensivist services. These providers can't balance bill you or ask you to give up your protections against balance billing.
If you get other services at in-network facilities, out-of-network providers can't balance bill you unless you provide written consent giving up your protections. There are no circumstances under which you are required to give up your protections from balance billing or get out-of-network care.
California state law has similar protections to those of the No Surprises Act.
Protections when balance billing is prohibited
When balance billing is prohibited, you are responsible only for your share of the cost of the care you received. This may include the copayments, coinsurance and deductibles that you would pay with an in-network provider or facility. Your health plan will pay out-of-network providers and facilities directly, and you shouldn't have to pay out of pocket for more than your share of the cost.
Your health plan generally must provide the following protections:
- Cover emergency services without requiring approval 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
- Count the amount you pay for emergency or out-of-network services toward your deductible and out-of-pocket maximum
If you believe you were wrongly billed
If you believe you were wrongly billed for care you received from a UCSF Health facility, please send a billing inquiry through UCSF Health's MyChart.
For more information on your rights under federal law, visit the Centers for Medicare & Medicaid Services' webpage about the No Surprises Act.
For more information on your medical billing rights under California state law, visit the California Department of Insurance's webpage about surprise medical bills or call the California Department of Managed Health Care at (888) 466-2219.