Cost Disclosure Notice

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 health care 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:

Emergency Services: 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 there 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 protections 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: a) Cover emergency services without requiring you to get approval for services in advance (prior authorization). b) Cover emergency services by out-of-network providers. c) 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. d) 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, please consider the following steps to resolve the issue:

Contact your insurer about the bill. Ask for clarification. Make sure that your insurer received a claim for the services for which you’re being billed. Ask if you are being held responsible for part of the billed amount, or for the entire bill.
File an internal appeal with your insurer. If your insurer does not agree to pay the claim, and you think it should be covered, you have the right to appeal within 180 days of your denied claim. An appeal means that you are asking your insurer to reconsider their decision not to pay. Keep in mind that if your bill is a true balance bill, the insurance company may not have been asked to pay and you can send them a copy to take care of it for you. IMPORTANT REMINDER: document all phone calls and keep copies of all paperwork.
File a complaint to the CO Department of Insurance. Through an external, or third-party appeal, the Department of Insurance will review your claim within 60 days of the denied internal appeal. File a complaint here: https://doi.colorado.gov/for-consumers/file-a-complaint
Tell your story to the Colorado Attorney General’s office. Call 800-222-4444 and let them know that you have experienced balance billing.
Visit https://www.hhs.gov/healthcare/index.html for more information about your rights under federal law.
Visit https://doi.colorado.gov/ for more information about your rights under Colorado state law.