Good faith estimate and disclosure

Our good faith estimate disclosure

When you get emergency care or treatment from out-of-network provider at an in-network hospital or ambulatory surgical center, you have protection from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other healthcare 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. 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.

You are always protected from balance billing for emergency services

If you have an emergency medical condition and receive emergency services from an out-of-network provider or facility, the provider or facility may not bill you more than 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 receive after you’re in stable condition, unless you give written consent and give up your protections against balance billing for these post-stabilization services.

Additionally, Colorado protects patients covered by managed care plans from surprise medical bills for healthcare services provided at an in-network facility by an out-of-network provider. Colorado also protects patients from surprise medical bills for emergency services, even if the services are out of network or provided by an out-of-network provider. Colorado law offers additional protections and requires patients to pay only their in-network cost sharing amounts.

What about services at an in-network hospital or ambulatory surgical center?

When you receive services at 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 is for 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 against balance billing.

If you get other services at these in-network facilities, out-of-network providers can’t balance bill 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.

Colorado law does not protect patients from surprise medical bills when they intentionally use an out-of-network provider.

When balance billing isn’t allowed, you also have the following protections:

• You are only responsible for paying your share of the cost, such as copayments, coinsurance and deductibles that you would pay if the provider or facility were 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:

• The Centers for Medicare & Medicaid Services (CMS) at https://www.cms.gov provides information on your rights under Federal law.
• Patients with Colorado-based health plans may also contact the Colorado State Division of Insurance at 303-894-7490 or 1-800-930-3745 or visit https://doi.colorado.gov.

Visit for more information about your rights under Federal law.

Good faith estimate disclosure

You have the right to receive a “good faith estimate” explaining how much your medical care will cost. Under the law, healthcare 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 healthcare provider gives you a good faith estimate in writing at least one business day before your medical service or item.
• If you receive a bill that is at least $400 more than your good faith estimate, you can dispute it.
• Save a copy or picture of your good faith estimate.

Questions?

If you have questions or want more information about your right to a good faith estimate, contact your Health District service provider, or visit cms.gov/nosurprises.