Your Rights and Protections Against
Surprise Medical Bills

Who this notice is for

This notice only applies to patients who have private health insurance, including coverage through an employer or a plan you bought yourself. It does not apply if you have Medicare or Medi-Cal, or if you are uninsured or paying for your own care.

If you are uninsured or paying for your own care, you have the right to receive a Good Faith Estimate of what your care will cost. Please ask Patient Financial Services at (213) 250-4200.

When you are treated by an out-of-network provider at an in-network hospital, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance, and/or deductible.

Barlow Respiratory Hospital is a long-term acute care hospital. We do not operate an emergency department and we do not provide emergency services, so the federal and state protections that apply to emergency care are not described in this notice.

What is "balance billing" (sometimes called "surprise billing")?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

"Out-of-network" means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called "balance billing." This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.

"Surprise billing" is an unexpected balance bill. This can happen when you can’t control who is involved in your care, such as when you are admitted to an in-network hospital but are unexpectedly treated by an out-of-network provider.

Certain services at an in-network hospital

When you get services from an in-network hospital, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other types of services at an in-network hospital, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

California law: Under California’s surprise billing law (Assembly Bill 72), if you have a health plan or insurance policy regulated by the California Department of Managed Health Care or the California Department of Insurance, and you receive non-emergency services at a health facility that is in your plan’s network, an out-of-network provider cannot bill you more than your in-network cost sharing. If an out-of-network provider wants your agreement to be billed at out-of-network rates, they must give you a separate written consent form at least 24 hours before your care, and that form must tell you that you may choose an in-network provider instead. California’s law does not apply to Medicare, Medi-Cal, or self-insured employer plans. Federal protections may still apply to those plans.

You are never required to give up your protections from balance billing. You also are not required to get out-of-network care. You can choose a provider in your plan’s network.

When balance billing isn’t allowed, you also have these protections:

• You are only responsible for paying your share of the cost, like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network. Your health plan will pay any additional costs to out-of-network providers and facilities directly.
• Generally, your health plan must base what you owe the provider or facility on what it would pay an in-network provider or facility, and show that amount in your explanation of benefits.
• Generally, your health plan must count any amount you pay for out-of-network services toward your in-network deductible and out-of-pocket limit.

If you think you have been wrongly billed

Please contact Barlow Respiratory Hospital Patient Financial Services at (213) 250-4200. You may also contact:

• California Department of Managed Health Care Help Center, 1-888-466-2219 or www.HealthHelp.ca.gov, for HMO and most managed care plans.
• California Department of Insurance, 1-800-927-4357 or www.insurance.ca.gov, for PPO and other insurance policies. If you are not sure what kind of plan you have, they can help you find out.
• Federal No Surprises Help Desk, 1-800-985-3059.

Visitwww.cms.gov/nosurprises/consumers for more information about your rights under federal law.

Free language assistance services and auxiliary aids and services are available to you at no cost. Ask any staff member or call (213) 250-4200.

Form # NSG 10039 • Barlow Respiratory Hospital • Revised 07/2026

Download full copy of Your Rights and Protections Against Surprise Medical Bills: English