Betty Chowa Los Angeles resident, had a cervical disc replaced August 2020 in a surgery center that was part of her Anthem Blue Cross PPO Network.

Thirteen months later, she was blinded by a bill for almost $2,000 the anesthesiologist who was part of his surgical team but not under contract with his PPO or preferred provider organization.

Chow, a 35-year-old veterinarian, says she discussed the bill with her boyfriend, a registered nurse. He told her about a California law that came into effect in 2017 and prohibits such “surprise bills” from out-of-network medical providers who work in in-network facilities.

Unfortunately, this law does not protect Chow or the nearly 6 million other Californians who receive health coverage through employers who pay employees’ medical bills out of their own cash. These “self-funded” plans are governed by the US Department of Labor — and are therefore beyond the reach of state law.

But a federal law that came into effect January 1st bridges this gap for the more than 100 million people enrolled in such health plans across United States, including these nearly 6 million Californians. And it covers millions more in all 32 states who either don’t have surprise bill laws or have laws that offer only partial protection.

New federal law, the No Surprises Act, also protects nearly one million Californians not covered by a 2009 law California Supreme Court decision that prohibits emergency physicians and other emergency service providers from charging HMO patients for out-of-network charges not paid by their insurers – a practice known as balance billing.

“Millions more Californians will now be protected from these bills that are not only unfair but endanger the economic security of families,” says Anthony Wrightexecutive director of Health Access California, a consumer advocacy group.

It’s high time. Surprise bills have inflicted financial hardship on millions of Americans for far too long.

When patients are seen by out-of-network providers they didn’t choose, it’s often a double whammy: they pay more out of pocket – even if their health plan covers some out-of-network care – and they can later receive balance bills from vendors that can total thousands of dollars.

Research shows surprise bills are common among the nearly 200 million WE residents enrolled in private health insurance plans.

A 2020 study found that 20% of privately insured patients who had elective surgery at a hospital that was part of their insurance network received surprise bills from providers who were not. Average anesthetist bills $1,219. Surgical assistant bills averaged more than double that amount.

“When patients pay their insurance premiums, they assume – and I think fairly presume – that they will be financially covered,” says Katie BergeDirector of Federal Government Affairs at the Leukemia and Lymphoma Society.

The unsurprising law covers everyone privately insured in employer-sponsored and individual/family health plans. Medicare and Medicaid already protect their enrollees from bad billing surprises.

The new federal law, which is largely in line with California’s, prohibits balanced billing for non-emergency care by out-of-network providers at in-network facilities and for most emergency room care at any establishment.

Insurers must cover these services at network rates, and providers cannot charge patients additional amounts.

Providers and health plans must negotiate how much the plan will pay, leaving patients out of the fray.

Federal law also protects against outrageous billing from out-of-network air ambulance services.

A California law entered into force in January 2020 does the same. But it does not cover the millions of people in federally regulated health plans and has been vulnerable to possible legal challenge because it may clash with the 1978 airline deregulation, which included air ambulances.

Where its provisions are stricter, federal law will prevail over state laws.

What about execution? The federal government will defer to the states in cases involving state-regulated plans, and in those involving federally-regulated plans if the target of the complaint is a provider, says Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy. But the federal government will step in if states refuse or cannot enforce the law, he says.

Federal health officials are sending letters about the application to each state’s governors.

Californiawith its strict laws against surprise billing, certainly has the means and experience to enforce the law, although it hasn’t seen a large number of cases.

Over the past four years, the Department of Managed Healthcare resolved 1,006 consumer complaints about balance billing, and 467 of them resulted in total refunds of nearly $1 million to registrants, says Rachel Arrezoladepartment spokesperson.

Of course, not all bills that surprise patients are regulated by federal or state law.

Sometimes people owe more than they thought on their deductible, or their cost share was higher than they thought, or their procedure was not covered by their health insurance plan, or the he establishment they had chosen was not part of their network.

So upgrade your insurance policy. Know what it covers and who it covers, what facilities are in the network, how much your outgoings are and how much of your deductible is left to pay.

This will help you determine if a bill is illegitimate. And there will always be illegitimate invoices – because people make mistakes. And some health professionals act in bad faith.

When you get a bill, don’t pay it right away. To ask questions. Compare it with the explanation of benefits you receive from your insurer – and if it hasn’t happened yet, wait for it.

If there’s a discrepancy between what your provider says and your health plan, call them both and try to iron out the issue.

If that doesn’t work, don’t be discouraged. You can file a complaint with your health insurance fund.

And if that doesn’t solve your problem, contact the Department of Managed Healthcare to open an appeal, either on its website (www.healthhelp.ca.gov) or by calling 1-888-466-2219.

The department also has a fact sheet that may answer some of your questions about California surprise billing law.

The federal government has launched a website (www.cms.gov/nosurprises) that can answer many of your questions about the law without surprises and allow you to file a complaint or dispute a bill. You can also contact a “no surprises” Federal Helpline at 1-800-985-3059.

If you are simply confused by medical bills or lack the confidence to dispute one on your own, the Health Consumer Alliance is a great resource. Find an office near you by going to www.healthconsumer.org or by calling 1-888-804-3536.

Chow, from hong kong who has been patient in the single-payer system there and in the UKsaid to be disconcerted by WE system, “where you pay for medical insurance, but then you have to pay more.”

Although California law does not protect her from the intervention of the anesthetist $2,000 bill and the new federal law is not retroactive, it nevertheless seems to be heading for a happy ending.

After three sample collection attempts by the anesthetist and several phone calls from Chow, Anthem agreed to drop the bill to $83 and update the anesthesiologist’s billing office. It still hasn’t happened, but Chow is hopeful.

“I don’t really understand what I’m responsible for,” she says, “except $83 is much less than $2,000.”

This story was produced by Kaiser Health Newsa national newsroom that covers health issues in depth. Kaiser Health News is an independent editorial program of Kaiser Family Foundation and not affiliated with Permanent Kaiser.