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Covered California and Obamacare related questions from consumers, employers and agents are answered by Phil Daigle with the best information available at the time. Archived entries may no longer be accurate as the Covered California and Obamacare knowledge-base is evolving quickly. TO REQUEST A PERSONAL RESPONSE INCLUDE EMAIL ADDRESS.

Will I Be Balance-Billed on my ER Visit?

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Question: With the much narrower networks in all EPO/PPO plans the chances of an out-of-network provider providing services to me on ER are high. Seems like in California, balance billing, where the out-of-network provider charges you the difference between what insurance pays and whatever rate they may please, has been banned for HMO plans since 2008. It is not so clear to me what is going on for PPO/EPO plans. Seems like consumers from PPO/EPO plans licensed by the California Department of Managed Health Care can't be subject to balance billing on ER visits according to this http://goo.gl/bqZBgf. Any idea if using the plans on Covered California one would not be subject to balance billing on ER visits?

Answer: No. Qualified health plans offered through Covered California are underwritten by private insurance companies licensed by the California Department of Managed Health Care or the California Department of insurance and as such all Covered California HMO, EPO, and PPO plans are subject to restrictions against out-of-network providers balance billing for emergency room services (not including ambulance services).


My daughter had to go to ER for what was thought to be appendicitis, they failed to inform her they were not in her health plan network. Now she is subject to Balance Billing resulting in roughly $5,000.00 for the ER and ER Physicians. Is she liable for these balances or should ER accept the amount allowed by Insurance Plan?


I have a similar issue with Blue Cross PPO Silver. The nearest urgent care that is an in network provider is 35 miles away using a a windy mountain road. Am I suppose to risk that drive??????? The blue shield patient bill of rights states that customers can expect reasonable access to care. Can I argue and win that using an urgent care so far away is not reasonable access when an urgent care out of network is 3 miles away?

PPO plans are NOT regulated by the Dept of Managed Health Care, they are regulated by the Dept of Insurance.

Balance billing is not an issue in HMOs because there is no out-of-network coverage other than emergency care. But even a trip to the in-network ER can result in out-of-network charges that are not covered under the PPACA. Lab and radiology services are often contracted to third-party vendors who do not contract with some or any HMOs or PPOs, so they can charge whatever they like and someone will have to pay the bill.

Balance billing has always been a feature of PPOs when it comes to out-of-network services. Many contracts use the words “usual, customary, and reasonable” to describe what the insurance company pays for out-of-network charges, and most often in relation to the in-network contracted rates, in addition to higher deductibles, copays, and/or coinsurance.

Out-of-network emergency services under the PPACA must be “covered” to the same extent that they are covered in-network, whether the plan is an HMO or a PPO, EPO, or POS.

And Phil is right, a person is not buying health insurance manufactured by Covered California (just like there is no insurance company known as COBRA). All of the policies are manufactured by insurance companies or other corporations (profit or not-for-profit) that offer contracts to pay for some or all of a person’s healthcare expenses.

What the PPACA has actually done to benefit healthcare in America is make most people realize they don’t know what their insurance actually covers or how it works. Like any other “game” — not knowing the rules puts you at a serious disadvantage.

People don’t like what they are seeing in some of the health plans now available. But, for the most part, there isn’t all that much that’s new. The higher costs are directly attributable to the mandate to cover all persons without regard to current health status or gender, and the restriction on charging a 64-year-old no more than 3x the cost of the same plan for a 21-year-old.

Think back to the Jon Lovitz character on Saturday Night Live: “64/21 = 3. Yeah! That’s the ticket!”

Is this also true for things like scheduled surgeries? I can just imagine that a lot of providers involved in some sort of non ER surgery, like an apendix or gallbladder removal where some of the players will be out-of-network given the ultra narrow networks even if the hospital you chose for surgery is in-network. This would mean that people who choose EPO and PPO plans could be on the hook for brutally high bills in a very unexpected way. You will hear that you have to make sure your doctors are in network, but for most surgery this is impossible/not practical to do as you have no idea who the anesthesiologist and the like will be beforehand.

Given the fact that the ACA has given access of PPO plans to people with much less resources this could be a big problem going forward causing lots of financial distress when people ‘thought’ they were on the hook for just their deductibles and their copays if they stayed in-netork, and then end getting services unknowingly from out-of-network providers that will balance bill them absurd amounts.

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