When you get emergency care or are treated by an out-of-network provider at Rady Children’s Hospital-San Diego (“Rady Children’s”), you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.
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, like a copayment, coinsurance or deductible. You may have additional 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” means providers and facilities that have not signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays, 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 plan’s deductible or annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you cannot 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. Surprise medical bills could cost thousands of dollars depending on the procedure or service.
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 they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You cannot 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.
California law protects enrollees in state regulated plans from surprise medical bills when an enrollee receives emergency services from a doctor or hospital that is not contracted with the patient’s health plan or medical group. In covered circumstances, providers cannot bill consumers more than their in-network cost sharing.
Certain Services at an In-Network Hospital or Outpatient Surgery Center
When you get services from an in-network hospital or outpatient surgery center, certain providers there may be out-of-network. In these cases, the most those providers can 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 cannot balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other types of services at these in-network facilities, out-of-network providers cannot balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also are not required to get out-of-network care. Other than when you are taken to an emergency room, you can generally choose a provider or facility in your plan’s network.
If you receive emergency services at Rady Children’s and you are not insured, our policy is to provide financial assistance to patients whenever possible. We will reach out to you to discuss our financial assistance programs. If you are admitted, we will work to ensure that you understand your rights and financial options.
When balance billing is not allowed, you also have these protections:
- You are only responsible for paying your share of the cost (like the copayments, coinsurance and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
- Generally, your health plan must: Cover emergency services without requiring you to get approval for services in advance (also known as “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 in-network deductible and out-of-pocket limit.
If you believe you have been wrongly billed or want additional information, you may contact any of the following:
- Hospital Billing Department. If your bill is for Rady Children’s hospital services, your guarantor number will begin with “F.” For questions regarding hospital billing, contact us at 858-966-4912 or email@example.com.
- Provider Billing Department. If your bill is from a physician for a specialty service, your guarantor number will begin with “S.” For billing questions for Rady Children’s Specialists of San Diego please contact us at 858-309-6290, 858-966-5420 or firstname.lastname@example.org.
- Your health plan.
- The Centers for Medicare and Medicaid Services (CMS), the federal agency overseeing these matters, has this informational site: http://www.cms.gov/nosurprises/consumers, and the following hotlines for complaints: 1-800-985-3059 (federally regulated plans) and 1-888-466-2219 (state regulated plans).
- Copies: If you would like an electronic or paper copy of this notice, please contact Customer Service: 858-966-4912 or email@example.com.