When you get emergency care or are treated by an out-of-network provider at an

in-network hospital or ambulatory surgical center, you are protected from

balance billing. In these cases, you shouldn’t be charged more than your plan’s

copayments, coinsurance and/or deductible.

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 islikelymore than in-network costs for the same service and might not

count toward your plan’s deductible or annual out-of-pocketlimit.

“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 treated by an out-of-network provider. Surprise medical

bills could cost thousands of dollars depending on the procedure orservice.

You’re protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-

network provider or facility,the most they can bill you is your plan’s in-network cost-sharing

amount (such as copayments, coinsurance, and deductibles). 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.

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

When you get servicesfrom an in-network hospital or ambulatory surgical center, 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 these in-network facilities, out-of-network providers can’t

balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also

aren’t required to get out-of-network care. You canchoose a provider or facility in

your plan’s network.

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

You’re only responsible forpaying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provideror 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:

Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
Cover emergency services by out-of-network providers.
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 benefits.
Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

If you think you’ve been wrongly billed, you may file a complaint with the federal government

at https://www.cms.gov/nosurprises/consumers or by calling 1-800-985-3059.

Visit www.cms.gov/nosurprises/consumers formore information about your rights under

federal law.

The law in your state may provide additional protections to you that are not provided by

federal law. For more information regarding your protections against Surprise Medical Billing

to to learn about making a complaint, please see the state-specific resources on the enclosed

page.

Sales Directors

Tim McPherson, National Sales Director

tmcpherson@apaths.net

(704) 246-9269