A surprise or balance medical bill happens when:
- You go to a heath care facility, like a hospital or a lab in your plan’s network and end up with a doctor who isn’t in network. You’re then charged more than you would have to pay for an in-network doctor.
- You’re taken to a non-contracted emergency room and billed for the remaining balance for the services you got that weren’t covered.
- You choose to go to an out-of-network health facility or receive services from an out-of-network provider.
While California law already safeguards consumers in Health Maintenance Organization (HMO) plans from surprise medical bills, some federally regulated health insurance plans, such as CalPERS’ Preferred Provider Organization (PPOs), aren’t protected from this practice.
Here’s the good news: As part of its year-end Continuing Appropriations Act (CAA), Congress recently approved protections against balance billing for federally regulated health insurance plans. This means CalPERS PPO members will be protected from most surprise medical bills starting January 1, 2022. The Act did not cover possible surprise bills for ground ambulance services, for example.
“It isn’t perfect, but the legislation gives critical protections to the 270,300 CalPERS members in our self-insured PPO plans, who aren’t currently safeguarded from surprise bills under California law,” said CalPERS Chief Health Director Don Moulds. “After years of advocating strenuously for better protections, we’re pleased to see this important legislation enacted.”
Risk of Surprise Billing Is Already Low for CalPERS Members
In 2019, only 3.2% of our PPO members received services from out-of-network medical providers or facilities. While the chance of getting a surprise medical bill is slim, you can avoid it entirely by getting services from in-network doctors and facilities.
Sometimes patients have no choice but to seek out-of-network care, particularly in the case of an emergency room visit. In those instances, we pay at a higher in-network percentage based on allowed amounts. Most providers accept these payments.
It’s important that our members be able to choose care from as large a medical network as possible. Anthem—which administers our PPO plans—has the broadest hospital and provider network in all of California, with over 82,000 network providers and hundreds of hospitals across the state’s 58 counties. You can avoid hidden fees by using Anthem’s Find Care tool before your visit to make sure your doctor participates in your plan.
Learn More About Surprise Medical Bills
Below are additional resources to help you make the best choices when it comes to your medical care.
- Consumer Protection from Surprise Medical Bills, California Department of Insurance
- ‘Surprise’ Billing Risk Is Low for CalPERS Members, CalPERS
- Surprise Medical Bills Fact Sheet (PDF), California Department of Managed Health Care
- The Perils of Seeing a Doctor Not in Your Plan, Anthem