If you suddenly become injured in a car crash or a slip and fall, you may not always be able to decide where you are taken for emergency treatment. If you are taken to an out-of-network hospital, these unforeseeable bills can be exorbitant. But now, with new laws, things are changing. If you live in Colorado and are not covered by the state’s law preventing surprise medical bills, you now have protection under federal law through the No Surprises Act.
The federal No Surprises Act, which took effect on January 1, 2022, and Colorado law both limit how much you can be billed if you get emergency care from an out-of-network hospital, or if you have an out-of-network doctor at an in-network hospital.
Before these laws were passed, it wasn’t uncommon for patients to receive large bills if they couldn’t verify ahead of time that everyone involved in their care was covered by their health insurance plan. Yet, even with these laws, those seeking emergency treatment may still face sticker shock after the fact.
Below are some frequently asked questions about the Colorado and federal laws banning surprise medical bills:
What does all the talk about networks mean?
Hospitals want to get paid as much as possible. Health insurance companies want to pay out as little as possible. It is a constant dance between the two to find a common ground. If they can agree on how to work together, then the health insurance company adds the hospital to their network.
Health insurance plans are set up to encourage patients to use in-network health care providers. For example, you may have to pay a higher percentage of the total cost of your hospital stay if you go to a hospital that is out-of-network. It’s allowed though because sometimes patients want to go to a specific hospital for a certain reason.
What the state and federal laws try to do is protect patients from unexpected bills if you didn’t intentionally pick an out-of-network hospital.
What protections do I have under the federal No Surprises Act?
Under the federal No Surprises Act, the protections apply to treatment you received in emergency rooms and air ambulances, as well as any post-emergency care that you needed before you could safely transfer to an in-network hospital.
Also, through the No Surprises Act, you can only be billed for what you would have paid with an in-network provider. The out-of-network hospital or health care provider can’t send you the difference between what they charged and what your insurance company was willing to pay.
When am I not protected?
The federal No Surprises Act covers free-standing emergency rooms, hospitals (including outpatient departments), and ambulatory surgery centers—if you need unforeseeable emergency care. Some urgent care centers may be covered if they provide the equivalent of emergency room care, but you should check with your insurance company before seeking treatment at one.
For other facilities, such as nursing homes, outpatient clinics, addiction treatment facilities, and non-hospital birthing centers, you are not protected by the No Surprises Act. Plus, ground ambulances are not protected by federal law.
Lastly, under the federal law, medical providers only need to give you a “good faith estimate” of what they may charge—if you are uninsured.
How is Colorado’s surprise billing law different?
Colorado’s surprise billing law took effect in 2020. It limits how medical providers ask you to waive your protections. Under the federal law, although medical providers need to get a patient’s consent to waive their protections 72 hours before planned procedures, patients may still feel that they have no choice but to waive those protections if they want care.
The state law also protects you if you’re transported by a privately-owned ground ambulance company. However, if a county emergency medical services department that isn’t in-network transports you, you are not protected.
Another important difference between the federal and state laws is what can happen once you’ve been stabilized after an emergency. Under Colorado law, if you went to an out-of-network hospital for an unexpected medical emergency, like a heart attack, you can’t be charged out-of-network rates until you’re well enough to decide if you want to stay in the out-of-network hospital and pay them or be transferred to an in-network hospital.
The No Surprises Act puts additional limits on when you could be charged out-of-network rates following an emergency. Specifically, under the federal law, post-stabilization care is considered emergency care until a physician determines the patient can travel safely to another in-network facility using non-medical transportation. In addition, that facility must be available and accept the patient. The law also requires that moving the patient will not cause the patient any unreasonable burdens.
Which law applies to me?
The No Surprise Act expands the surprise billing protections to people with insurance plans who are not regulated under the Colorado surprise billing law. If your insurance card has “DOI” on it, then the Colorado regulates your plan and state protections apply to you. Most large-group plans and plans not regulated by the state will be governed by the No Surprises Act.
The hope is that the state and federal laws will align in time, making things clearer.
What should I do?
If you’re scheduling a medical procedure, you should still check whether your providers and facility are in-network. The Colorado surprise billing law and the No Surprise Act are meant to prevent unforeseeable large bills—and what you may think is a reasonable amount of due diligence may be different from the legal standard. So, it is always best to try to see if any medical care is in-network before undergoing the care.
If you have questions or if you are not sure who to turn to about the new law, the No Surprises Help Desk at 800-985-3059 is available to answer your question. If you think you have been wrongly billed, you can also contact the No Surprises Help Desk to file a complaint if your plan is regulated by federal law. There are also patient advocacy groups that– may be able to send you in the right direction.
If your state law applies to your plan, you will need to contact your insurer and file an internal appeal. If your complaint is not resolved, file a claim with the Division of Insurance. You can also tell your story to the Office of the Colorado Attorney General.