No Surprise Act Notice

Your Rights and Protections Against Surprise Medical Bills

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

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 treated by an out-of-network provider.

You are 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 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.

[Insert plain language summary of any applicable state balance billing laws or requirements OR state-developed model language as appropriate]

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 to be balance billed.

If you get other 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 care out-of-network. You can choose a provider or facility in your plan’s network.

For information about state-enacted balance billing protections that might be applicable to you, see the last section of this notice.

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 and facilities directly.
• Your health plan generally must:
  • Cover emergency services without requiring you to get approval for services in advance (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 deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact the U.S. Department of Labor’s Employee Benefit Security Administration at 1-866-444-3272 or the Health and Human Services Administration at: 1-800-985-3059.

Visit this link for more information about your rights under federal law.

State-enacted balance billing protections that might be applicable to you:

For information about additional, state-enacted surprise billing protections that might be applicable to you, see one or more of the following links for the state in which you live or work. Please note that whether you have protections under state law will depend on whether the state has enacted such protections and the scope of those protections and may also depend on whether your group health insurance benefits are provided under an insured plan, a self-insured plan, or a self-insured plan that has opted into relevant state-enacted protections.

Some of the links below are to a state’s general department of insurance website because the state did not have a webpage devoted to surprise billing information at the time this notice was prepared:

Arizona:
See here and here for information about potential surprise billing and other protections under Arizona law, or contact the Arizona Department of Insurance and Financial Institutions at (602) 364-3100.

California:
See here for information about potential surprise billing and other protections under California law. In California, if you do not agree with your health plan’s response or they take more than 30 days to fix the problem, you can file a complaint with the Department of Managed Health Care, the state regulator of health plans. You can file a complaint by visiting www.HealthHelp.ca.gov or by calling 1-888-466-2219.

Colorado:
See here for information about potential surprise billing and other protections under Colorado law. In Colorado, if you believe you’ve been wrongly billed you may also call the Colorado Assistance Program at 1-303-839-1261 or visit the Colorado Consumer Health Initiative website at www.cohealthinitiative.org.

Connecticut:
See here for information about potential surprise billing and other protections under Connecticut law, and here for information from Connecticut regarding federal protections. In Connecticut, if you believe you’ve been wrongly billed you may also call the Connecticut Insurance Department at (800) 203-3447.

Delaware:
See here for information about potential surprise billing protections under Delaware law, and here for information from Delaware regarding federal protections. In Delaware, if you believe you have been wrongly billed, you may also call the Delaware Department of Insurance at (302) 259-7552.

Florida:
See here for information about potential surprise billing protections under Florida law. In Florida, if you believe you’ve been wrongly billed you may contact the Office of Insurance Regulation.

Georgia:
See here for information about potential surprise billing protections under Georgia law. In Georgia, if you believe you’ve been wrongly billed you may also contact the Office of Commissioner of Insurance at (800) 656-2298 or file a complaint here.

Illinois:
See here for information about potential surprise billing protections under Illinois law, and see here for information from Illinois regarding federal protections. In Illinois, if you believe you have been wrongly billed you may also contact the Illinois Department of Insurance at 866-445-5364.

Indiana:
See here for information about potential surprise billing protections under Indiana law. In Indiana, you may also contact the Indiana Department of Insurance here.

Iowa:
See here for information about potential surprise billing protections under Iowa law, and here for information from Iowa regarding federal protections. You may also contact the Iowa Division of Insurance at 515-654-6600.

Maine:
See here for the Maine law regarding surprise billing. You may also file a complaint with the Maine Bureau of Insurance at 800-300-5000 or 207-624-8475.

Maryland:
See here for information about potential surprise billing protections under Maryland law, and here for information from Maryland regarding federal protections. If you have questions, concerns or wish to file a complaint, the Maryland Insurance Administration can be reached at 1-800-492-6116, or you can file a complaint online here.

Massachusetts:
See here for information about potential surprise billing and other protections under Massachusetts law. You may also contact the Massachusetts Health Policy Commission at (617) 979-1400.

Minnesota:
See here for information about potential surprise billing and other protections under Minnesota law, and here for information from Minnesota regarding federal protections. You may also contact the Minnesota Department of Health at 1-800-657-3916.

Mississippi:
See here and here for information about potential surprise billing and other protections under Mississippi law. You may also call the Mississippi Insurance Department at 1-800-562-2957.

Missouri:
See here for information about potential surprise billing and other protections under Missouri law. You may also contact the Missouri Department of Commerce and Insurance at 573-751-4126.

Michigan:
See here for information about potential surprise billing and other protections under Michigan law. You may also contact the Michigan Office of Insurance and Financial Services by calling the Office Monday through Friday 8 a.m. to 5 p.m. at 877-999-6442 or filing a complaint here.

Nebraska:
See here for information about potential surprise billing and other protections under Nebraska law. You may also contact the Nebraska Department of Insurance at 1-877-564-7323. Additional information is available here.

Nevada:
See here for information about potential surprise billing and other protections under Nevada law. You may also contact the Nevada Division of Insurance at (888)-872-3234.

New Hampshire:
See here for information about potential surprise billing and other protections under New Hampshire law. You may also contact the New Hampshire Insurance Department at that same site.

New Jersey:
See here for information about potential surprise billing and other protections under New Jersey law. You may also contact the New Jersey Department of Banking and Insurance by calling the Department at 609-292-7272.

New Mexico:
See here for information about potential surprise billing and other protections under New Mexico law. You may also contact the New Mexico Superintendent of Insurance by calling 855-427-5674 or filing a complaint here.

New York:
See here for information about potential surprise billing and other protections under New York law. You may also contact the New York Department of Financial Services by calling the Department at (800) 342-3736, or you may file a complaint here.

North Carolina:
See here for information about potential surprise billing and other protections under North Carolina law, and here for general information regarding health insurance protections. You may also contact the North Carolina Department of Insurance at (855)-408-1212.

Ohio:
See here for information about potential surprise billing and other protections under Ohio law. In Ohio, if you have surprise billing questions or concerns, you may also contact the Department of Insurance at 1-800-686-1526, here and here.

Oregon:
See here for information about potential surprise billing and other protections under Oregon law. In Oregon, you may also contact Oregon’s Division of Financial Regulation to speak with a consumer advocate or file a complaint in any of the following ways:
• Phone: 888-877-4894 (toll-free)
• Email: DFR.InsuranceHelp@dcbs.oregon.gov
• Website: File a complaint.

Pennsylvania:
See here for information about potential surprise billing and other protections under Pennsylvania law, and here for information from Pennsylvania about federal protections. You may also contact the Pennsylvania Insurance Department at 1-877-881-6388 or TTY/TDD at 717-783-3898.

Rhode Island:
See here for information about potential surprise billing and other protections under Rhode Island law, and here for general information about health insurance protections in the state. You may also contact the Insurance Division of the Rhode Island Department of Business Regulation at (401) 462-9520.

Texas:
See here for information about potential surprise billing and other protections under Texas law, and here for information regarding health care providers’ obligations to comply with Texas requirements. You may also contact the Texas Department of Insurance at this site or by calling 800-252-3439.

Vermont:
See here for the Vermont law supplying balance billing protection, and here for general information about potential surprise billing and other protections under Vermont law. You may also contact the Vermont Department of Financial Regulation at 833-DFR-HOTLINE.

Virginia:
See here for information about potential surprise billing and other protections under Virginia law. Consumers covered under (i) a fully-insured policy issued in Virginia, (ii) the Virginia state employee health benefit plan, or (iii) a self-funded group that opted-in to the Virginia protections are also protected from balance billing under Virginia law. You may also contact the Virginia State Corporation Commission Bureau of Insurance here or by calling 1-877-310-6560.

Washington:
If you believe 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; and/or file a complaint with the Washington State Office of the Insurance Commissioner at their website or by calling 1-800-562- 6900. Visit https://www.cms.gov/nosurprises for more information about your rights under federal law. Visit the Office of the Insurance Commissioner Balance Billing Protection Act website for more information about your rights under Washington state law.

West Virginia:
See here for information about potential surprise billing and other protections under West Virginia law, and here for information from West Virginia regarding federal protections. You may also contact the West Virginia Offices of the Insurance Commissioner at 1-888-TRY-WVIC (1-888-879-9842).