No Surprises Act & Good Faith Estimates
Your Rights and Protections Against Surprise Medical Bills
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 healthcare 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:
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.
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 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.
If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protection 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.
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, you may contact 1-800-985-3059.
Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
- You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
- Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
- If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
- Make sure to save a copy or picture of your Good Faith Estimate.
Patient Notice of Financial Assistance
Our hospital is committed to providing quality care to our community. To keep that commitment, we must work with you and your insurance carrier to help manage costs.
Our hospital requests payment for services at the time of discharge from the Outpatient and Emergency Departments. A Patient Access staff member will notify you of your financial obligation, such as insurance co-payments or self-pay responsibility. This will be collected during the discharge process. There are organizations (such as the Health Consumer Alliance at https://healthconsumer.org) that can help you understand the billing and payment process. You can find a list of shoppable services offered by our hospital by clicking here.
For patients who do not have insurance coverage, there are alternate funding and payment plan options offered by our hospital. Our Patient Access staff will work with you to identify the best payment option based on government or hospital rules and regulations.
The following is an overview of the financial assistance programs provided by our hospital.
Eligibility and Enrollment Services (EES)
The Eligibility and Enrollment Services Program is a hospital service provided to you at no cost. You may qualify for government programs, or for coverage thru the California Health Exchange, which would pay for all or part of your hospital and medical expenses. Our Patient Advocates will provide applications and are available to assist you in the application process.
Charity Care Program—Financial Assistance
A Financial Assistance Program is available to patients that do not have the means to pay for hospital expenses and do not qualify for any Medical Eligibility Programs. You may qualify if your household income is below 400% of the federal poverty limit and you are either uninsured or have medical expenses that exceed 10% of your annual household income. To be considered for the financial assistance, you will be required to provide information on your household finances through a confidential Financial Application. Documentation will be requested to verify your circumstances in order to determine eligibility. Please contact EES at (800) 374-4637 for additional information.
Uninsured Discount Program
All Uninsured Patients are eligible for discounts. The discount is similar to rates paid by commercial insurance payors and is offered to you under an Uninsured Discount Program.
A non-profit credit counseling service may be available in your area.
Outside Assistance Programs For Which You May Qualify:
- Temporary Assistance for Needy Families
- Social Security Disability
- Medical Low Income Adults
- Supplemental Security Income
- County Indigent
- Victims of a Violent Crime Fund
In addition, you may qualify for the Healthy Families Program, California Children's Services program or coverage through the California Health Exchange. In some cases, you may be eligible for coverage through Covered California or Medi-Cal for care that was provided prior to your application to these programs. Your EES representative can provide you with more information.
Contact Information: (800) 374-4637