Your Protections from Surprise Medical Bills

If you have a health plan that is subject to the federal No Surprises Act, you have protections that limit what you can be billed in certain out-of-network situations.

When these protections apply, you generally pay only your plan's in-network cost-sharing amount (copayment, coinsurance, and/or deductible).

You generally cannot be balance billed for:

• Emergency services from out-of-network providers or facilities.
• Certain services from out-of-network providers at an in-network hospital or ambulatory surgical center (often called "ancillary services," such as anesthesia, radiology, pathology, and laboratory).

When You May Be Asked to Waive Protections

For some non-emergency services, an out-of-network provider may ask you to sign a separate notice and consent form allowing you to be balance billed, where permitted by law.

You are not required to sign such a consent to receive care.

Good Faith Estimates for Uninsured or Self-Pay Patients

If you do not have insurance, or if you choose not to use your insurance for a scheduled non-emergency service, you can request a Good Faith Estimate of expected charges before you receive care.

If you receive a bill that is at least $400 more than a required Good Faith Estimate, you may be able to dispute the charges through a federal process.

Help and More Information

Learn more at www.cms.gov/nosurprises .

If you believe you've been wrongly billed, you can contact the No Surprises Help Desk at 1-800-985-3059 .

This notice is provided for informational purposes and does not change your health plan benefits or the terms of your plan.