Disclosure for Uninsured or Self-Pay Patients: You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost
Under the Surprise Billing Act, healthcare providers are required to give patients who don’t have insurance or who are not using insurance an estimate of the cost of medical items and services that they will receive.
• You have the right to receive a Good Faith Estimate for the total expected cost of any nonemergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
• Make sure your healthcare 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 healthcare 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.
For questions or more information about your right to a Good Faith Estimate, visit https://www.cms.gov/nosurprises or call (800) 985-3059.
Surprise/Balance Billing Disclosure Form
What is surprise/balance billing, and when does it happen?
If you are seen by a healthcare provider or use services in a facility or agency that is not in your health insurance plan’s provider network, sometimes referred to as “out-of-network,” you may receive a bill for additional costs associated with that care. Out-of-network healthcare providers often bill you for 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:
If you are receiving emergency services, the most you can be billed for is your plan’s in-network cost-sharing amounts, which are copayments, deductibles, and/or coinsurance. You cannot be balance-billed for any other amount. 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 balance-billed for these post-stabilization services. This includes both the emergency facility where you receive emergency services and any providers who see you for emergency care.
Nonemergency Services at an In-Network or Out-of-Network Healthcare Provider
If you are treated by an out-of-network provider at an in-network hospital or ambulatory (outpatient) surgical center, you are protected from surprise billing or balance billing. 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 are never required to give up your protections from balance billing. You also are not required to get care out-of-network. You can choose a provider or facility in your plan’s network.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. In this case, the most you can be billed for covered services is your in-network cost-sharing amount, which are copayments, deductibles, and/or coinsurance. These providers cannot balance-bill you for additional costs.
• Your insurer will pay out-of-network providers and facilities directly.
• 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, facility, hospital, or agency must refund any amount you overpay within sixty (60) days of being notified.
• Your health plan generally must cover emergency services without requiring you to get approval for services in advance (prior authorization).
• Your insurer will 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 want to file a complaint against your healthcare provider, you can submit an online complaint by visiting this website: https://www.colorado.gov/pacific/dora/DPO_File_Complaint.
If you think you have received a bill for amounts other than your copayments, deductible, and/or coinsurance, please contact the billing department, Colorado Division of Insurance at (303) 894-7490 or (800) 930-3745, or the U.S. Department of Health & Human Services at (800) 985-3059. Visit https://www.cms.gov/nosurprises for more information about your rights under federal law.
Please contact your health insurance plan at the number on your health insurance ID card or the Colorado Division of Insurance with questions.