State and federal laws protect you and your loved ones from large surprise medical bills by prohibiting health plans from billing you more when you unknowingly receive care from out-of-network providers — practice known as surprise billing.
What’s the Issue?
Each year, a few CalPERS members receive surprise medical bills from their health plan after receiving care from providers outside their health plan’s network. For example:
- You go to a health care facility within your plan’s network (like a hospital or a lab), but during your visit, you’re treated by a provider who is not a part of your plan’s network. You then receive a bill for the difference between the in-network and out-of-network amount.
- You’re taken to an out-of-network emergency room or treated by an out-of-network provider during an emergency room visit and are billed for the remaining balance for the out-of-network services you received.
Protections for HMO Members
State law protects members in health maintenance organization (HMO) plans from the practice of surprise billing, and Medicare and Medicare Advantage plans have their own limits and protections.
CalPERS members in HMO plans are protected under the Knox-Keene Act, which prohibits emergency department providers from billing patients for out-of-network emergency services. In addition, Assembly Bill 72 (2016) provides that, if a patient receives services at an in-network facility by an out-of-network provider, the patient is only required to pay the in-network price for those services.
Protections for PPO Members
The federal No Surprises Act offers similar protections for CalPERS’ preferred provider organization (PPO) plan members for most — but not all — services. For example, federal law doesn’t cover possible surprise bills for ground ambulance, certain urgent care services, or bills for services the member consented to receive from out-of-network providers.
The federal law aims to protect patients from unexpected medical bills by prohibiting providers from billing them directly. Instead, providers and insurers must work together to determine appropriate payment amounts. The law also seeks to ensure you have access to up-to-date information about which providers are in the health care network, and provides a process for filing complaints, appeals, and resolving disputes.
Federal protections, through the independent dispute resolution process, also safeguard patients who are exposed to out-of-network charges resulting from contract disputes between the provider and the insurer.
Learn More and Spread the Word
These laws don’t just help protect CalPERS health members and dependents. They also apply to your friends and neighbors with HMO, PPO, Medicare, and Medicare Advantage plans. So, spread the word!
If you think you’ve been wrongly billed, contact your health plan and ask them to explain the bill. If you’re not satisfied with your health plan’s decision:
- Non-Medicare CalPERS HMO plan members can contact the California Department of Managed Health Care’s online Help Center or call them toll free at (888) 466-2219 or via the DMHC TDD line (1-877-688-9891).
- Non-Medicare CalPERS PPO plan members can call the federal No Surprises Help Desk at (800) 985-3059, visit the Centers for Medicare and Medicaid Services website, or check out this helpful flyer (PDF).
- Medicare CalPERS plan members can contact CalPERS for general assistance by calling 888 CalPERS (or 888-225-7377) or by sending us a secure message via your myCalPERS account (find out more about signing up for and using myCalPERS).