What steps should I take to ensure my emergency room visit is covered by my California health plan, even if the hospital is out-of-network?

Under California law, your health plan must cover emergency services at any hospital, regardless of its network status. Here are the steps to ensure you are only responsible for your in-network cost-sharing amounts. Step 1: Get Immediate Medical Attention In a medical emergency, go to the nearest emergency room. Do not delay care to find an in-network hospital. Your health plan is required to cover your care based on the "prudent layperson" standard, which means if you reasonably believe you are experiencing a medical emergency, it must be treated as one. Step 2: Collect All Documents Keep a file with every piece of paper you receive. This includes your hospital discharge papers, all bills from the hospital and any doctors (like anesthesiologists or radiologists), and the Explanation of Benefits (EOB) sent by your health plan. Step 3: Review Your Explanation of Benefits (EOB) Once your health plan processes the claim, you will receive an EOB. This document will show what the plan paid and what your share of the cost is. For a covered emergency, this amount should not be more than your normal in-network copay, coinsurance, or deductible. Step 4: Contact Your Health Plan if Billed Incorrectly If you receive a bill from the hospital or a doctor for more than your in-network cost-sharing amount (this is called "balance billing"), call your health plan immediately. Inform them that under California's No Surprises Act, you cannot be balance-billed for out-of-network emergency services. Step 5: File a Formal Grievance or Appeal If a phone call does not resolve the issue, you must file a formal appeal with your health plan. Follow the instructions in your plan documents. You typically have 180 days from the date of the EOB to file an appeal. Submit copies of your bills and EOB with your appeal letter. Step 6: Request an Independent Medical Review If your health plan denies your appeal, you have the right to an Independent Medical Review (IMR) from the state. For most plans (HMOs and many PPOs), you file this request with the Department of Managed Health Care (DMHC). You can call their Help Center at 1-888-466-2219 or visit their website. Important Details and Nuances: After you are stabilized, your health plan may require you to transfer to an in-network facility if it is medically safe to do so. You must cooperate with a safe transfer. If you refuse, you may become financially responsible for care received after that point. Warnings and Limitations: These protections apply specifically to emergency and post-stabilization care. They do not apply to non-emergency services you choose to receive at an out-of-network facility. This is general information and does not constitute legal advice. For complex situations, especially those involving large bills or disputes over what constitutes "stabilized care," you should consult with a qualified California attorney.