When am I protected from surprise medical bills? Answers about Colorado law and new federal No Surprises Act

Coloradans not covered by the state’s law preventing surprise medical bills now have similar protection under federal law, but there are a few important differences.

Both Colorado law and the federal No Surprises Act, which took effect Jan. 1, limit how much you can be charged if you get emergency care from an out-of-network hospital, or happen to have an out-of-network doctor at an in-network hospital.

Until recently, patients have been hit with bills, sometimes adding up to tens of thousands of dollars, if they couldn’t ensure everyone involved in their care team had a contract with their insurance companies.

Despite the name, the No Surprises Act doesn’t mean you won’t get a larger bill than you expected. For example, if you get relatively low-level care, like stitches, at an emergency room, you might still have some sticker shock when you see the fees that come with it. Those situations aren’t considered surprise bills under state or federal law.

Below are answers to some common questions about the Colorado and federal laws.

What’s all this about networks?

This goes back to the never-ending dance between health care providers and insurance companies. Hospitals want to get paid as much as possible, and insurers want to pay out as little as possible. If they can reach an agreement that satisfies both, the hospital is part of the insurer’s contracted network.

This matters for customers because insurance plans are set up to encourage you to use in-network providers. For example, some plans make you pay a higher percentage of the total cost of your hospital stay if you go to a facility that’s not in their network. That’s still allowed for nonemergency care (for example, if you choose an out-of-network hospital for a planned surgery, because you’ve heard good things from people who went there).

What the federal and state laws attempt to do is protect you from unexpected bills if you didn’t intentionally go out-of-network.

What protections do I have under the federal law?

Under the No Surprises Act, your insurance company can only bill you what you would pay with an in-network provider. The hospital or health care provider also can’t send you a “balance bill” — the difference between what they charged and what your insurance company was willing to pay.

For example, say you normally owe $100 for an emergency room visit under your health plan, your insurance company pays $5,000 to in-network emergency rooms for the type of care you received and the out-of-network hospital you went to wants to charge $10,000. If you went an out-of-network ER, you still would owe $100, and the hospital couldn’t send you a bill for the $5,000 your insurance company didn’t cover.

The protections apply to care in emergency rooms and air ambulances, as well as any post-emergency care that’s needed before you could safely transfer to an in-network facility, according to an analysis from the Kaiser Family Foundation.

You’re also protected if you go to an in-network hospital and receive care from an out-of-network provider. For example, if you chose an in-network hospital and surgeon, but the anesthesiologist who puts you under is out-of-network, you still pay the in-network rate for your sedation.

If the insurance company and the provider can’t agree on what the services should have cost, that’s generally not going to be your problem, and they can settle it through arbitration. (Health industry trade groups aren’t happy about the details, which they feel give too much leverage to insurers.)

“In the vast majority of cases, regardless of what insurance plan you have, you should be largely protected from balance billing,” said Adam Fox, deputy director of the Colorado Consumer Health Initiative.

When am I not protected?

The federal law covers hospitals (including their outpatient departments), free-standing emergency rooms and ambulatory surgery centers. Some urgent care centers may be included, if they’re licensed to provide the equivalent of emergency room care, but you should check before seeking care at one.

You’re not protected in other facilities, like non-hospital birthing centers, addiction treatment facilities, nursing homes or outpatient clinics. The federal law also doesn’t include ground ambulances.

If you’re uninsured, the law only requires that providers give you a “good faith estimate” of what they may charge.

How is the Colorado law different?

Colorado’s surprise billing law, which took effect in 2020, limits the circumstances in which providers can ask you to waive your protections. One concern about the federal law is that, though providers are supposed to get patients’ consent to waive protections 72 hours before planned procedures, patients may still feel ambushed at the last minute and that they have no choice but to sign if they want care, Fox said.

“That is one of the key differences” between the laws, he said.

The state law also protects you if you’re transported by a privately-owned ground ambulance company. You’re not protected if a county emergency medical services department that isn’t in-network with your insurance transports you, though.

“At the federal level that is very much a gap,” Fox said. “At the state level, we still have a bit of a gap.”

Another important difference 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 something 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 place and pay them, or be transferred to an in-network hospital.

Federal regulations related to the No Surprises Act put additional limits on when you could be charged out-of-network rates following an emergency, said Megan Axelrod, regulatory policy manager at the Colorado Hospital Association.

Under those rules, you must be well enough that the transfer doesn’t require an ambulance, and there must be an in-network hospital within a reasonable traveling distance. So, for example, if your heart attack took place on vacation in a part of the country where your insurance company doesn’t contract with any hospitals, you can’t be charged out-of-network rates, since it’s not feasible for you to drive for hours while still recovering.

“The goal is the same, but (the Centers for Medicare and Medicaid Services’ guidance) is way more specific and in the weeds,” she said.

Which law applies to me?