California Billing Rights

Additional State-Law Protections for Patients with State-Regulated Health Plans

• California law AB 72 protects consumers from surprise medical bills when they get non-emergency services, go to an in-network health facility, and receive care from an out-of-network provider without their consent. Facilities include hospitals, ambulatory surgery centers or other outpatient settings, laboratories, and radiology and imaging centers.
  • In this case, the law states that consumers only have to pay their -network cost sharing (co-pays, co-insurance or deductibles).
  • Medical providers are prohibited from sending consumers out-of-network bills when the consumer followed their health insurer’s requirements and received non-emergency services in an in-network facility.
  • Consumers following their health insurer’s requirements are protected from having their credit hurt, wages garnished, or liens placed on their primary residence.
  • If you have a health insurance policy with an out-of-network benefit, such as a PPO, you can choose to go to an out-of-network provider. If you go to an in-network facility and want to see an out-of-network provider, you have to give your permission in writing by signing a form provided by the out-of-network provider at least 24 hours before you receive care. The form must be separate from any other document used to obtain consent for any other part of the care or procedure and should inform you that you can receive care from an in-network provider if you choose. At the time consent is provided, the out-of-network provider shall give the consumer a written estimate of the consumer’s total out-of-pocket cost of care.
• California law AB 716 prohibits ground ambulance providers from balance billing enrollees and prohibits such providers from attempting to collect from an enrollee amounts greater than the in- network cost-sharing amount owed by the enrollee.

Additional State Guidance

California’s laws addressing surprise and balance billing apply to people with health insurance policies or plans regulated by the Department of Insurance or the California Department of Managed Health Care that were issued, amended, or renewed on or after July 1, 2017. It does not apply to Medi-Cal plans, Medicare plans or self-insured plans. If you do not know what kind of plan you have, you can call the Department of Insurance Help Center at 800-927-4357 or visit www.insurance.ca.gov/01-consumers/101-help/index.cfm.

Filing a Complaint

If you get a surprise bill for more than your in-network cost share (co-pay, co-insurance or deductible), file a grievance/complaint with your health plan or insurer and include a copy of the bill. Your health plan or insurer will review your grievance and should tell the provider to stop billing you.

If you do not agree with your health plan’s response or they take more than 30 days to fix the problem, you can file a complaint with the Department of Managed Health Care, the state regulator of health plans. You can file a complaint by visiting www.HealthHelp.ca.gov or calling 888-466-2219.

If you do not agree with your health insurer’s response or would like help from the California Department of Insurance to fix the problem, you can file a complaint with us online at www.insurance.ca.gov/01-consumers/101-help/index.cfm or by calling 800-927-4357.

State Agency Contact Information

California Department of Managed Health Care (For Health Plans)

Phone: 800-927-4357
Website: www.insurance.ca.gov/01-consumers/101-help/index.cfm

Additional Information

Visit www.cms.gov/nosurprises/consumers or call 800-985-3059 for more information about your rights under federal law.