No Surprises Act Disclosure Notice

YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS

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(OMB Control Number: 0938-1401)

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When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatorysurgical center, you are protected from surprise billing or balance billing.

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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,     such as a copayment, coinsurance, and/or a deductible. You may have other 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” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay 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 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 – like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treatedby an out-of-network provider.

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You are protected from balance billing for:

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Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable  condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

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Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may 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 tobe balance billed.

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

You’re never required to give up your protection from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

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

• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers andfacilities

• Your health plan generally must:

  • Cover emergency services without requiring you to get approval for services in advance (priorauthorization).

  • Cover emergency services by out-of-network

  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of

  • Count any amount you pay for emergency services or out-of-network services toward yourdeductible and out-of-pocket

 

If you believe you’ve been wrongly billed, you may contact: No Surprises Help Desk at 1-800-985-3059 from 8 am to 8 pm EST, 7 days a week or submit a complaint online at https://www.cms.gov/nosurprises/consumers.

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Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf for more information about your rights under Federal law.