NO SURPRISES ACT NOTICE Professional services rendered by independent healthcare professionals are not YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS part of the hospital bill. These services will be billed to the patient separately. Please understand that physicians or other healthcare professionals may be called upon to provide care or services to you or on your behalf, but you may When you get emergency care or get treated by an out‑of‑network not actually see, or be examined by, all physicians or healthcare professionals provider at an in‑network hospital or ambulatory surgical center, you are participating in your care; for example, you may not see physicians providing protected from surprise billing or balance billing. radiology, pathology, and EKG interpretation. In many instances, there will be a separate charge for professional services rendered by physicians to you or on your behalf, and you will receive a bill for these professional services that 1. What is “balance billing” (sometimes called “surprise billing”)? is separate from the bill for hospital services. These independent healthcare When you see a doctor or other health care provider, you may owe certain out‑ professionals may not participate in your health plan and you may be responsible of‑pocket costs, such as a copayment, coinsurance, and/or a deductible. You for payment of all or part of the fees for the services provided by these may have other costs or have to pay the entire bill if you see a provider or visit physicians who have provided out‑of‑network services, in addition to applicable a health care facility that isn’t in your health plan’s network. amounts due for copayments, coinsurance, deductibles, and non‑covered services. “Out‑of‑network” describes providers and facilities that haven’t signed a We encourage you to determine if independent healthcare professionals contract with your health plan. Out‑of‑network providers may be permitted to are participating in the Plan by checking the Plan’s website at www. bill you for the difference between what your plan agreed to pay and the full MyHealthToolkitLA.com/links/FMOLHS and/or calling Member Services at (833) amount charged for a service. This is called “balance billing.” This amount is 468‑3594. You may access these websites from home. If you have any questions likely more than in‑network costs for the same service and might not count about how to do this, please contact [email protected] or call 1‑833‑482‑7547. toward your annual out‑of‑pocket limit. “Surprise billing” is an unexpected balance bill. This can happen when you When balance billing isn’t allowed, you also have the following protections: can’t control who is involved in your care — like when you have an emergency » You are only responsible for paying your share of the cost (like the or when you schedule a visit at an in‑network facility but are unexpectedly copayments, coinsurance, and deductibles that you would pay if the treated by an out‑of‑network provider. provider or facility was in‑network). Your health plan will pay out‑of‑ network providers and facilities directly. 2. You are protected from balance billing for: » Your health plan generally must: » Cover emergency services without requiring you to get approval for Emergency services services in advance (prior authorization). If you have an emergency medical condition and get emergency services from – Cover emergency services by out‑of‑network providers. an out‑of‑network provider or facility, the most the provider or facility may bill – Base what you owe the provider or facility (cost‑sharing) on what it you is your plan’s in‑network cost‑sharing amount (such as copayments and would pay an in‑network provider or facility and show that amount in coinsurance). You can’t be balance billed for these emergency services. This your explanation of bene昀椀ts. includes services you may get after you’re in stable condition, unless you give – Count any amount you pay for emergency services or out‑of‑network written consent and give up your protections not to be balanced billed for these services toward your deductible and out‑of‑pocket limit. post‑stabilization services. If you believe you’ve been wrongly billed, you may contact the Department of Health care services may be provided to you at a network health care facility Health and Human Services (HHS) at 1‑800‑985‑3059. by facility‑based physicians who are not in your health plan. You may be responsible for payment of all or part of the fees for those Out‑of‑Network Visit: https://www.cms.gov/nosurprises/consumers for more information about Services, in addition to applicable amounts due for co‑payments, coinsurance, your rights under federal law. deductibles and non‑Covered Services. Speci昀椀c information about In‑Network and Out‑of‑Network facility‑based Newborns’ and Mothers’ Health Protection Act physicians can be found at www.MyHealthToolkitLA.com/links/FMOLHS and by Statement of Rights under the Newborns’ and Mothers’ Health Protection Act calling Member Services at (833) 468‑3594. You may access these websites from home. If you have any questions about how to do this, please contact Group health plans generally may not, under Federal law, restrict bene昀椀ts for any [email protected] or call 1‑833‑482‑7547. hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit Certain services at an in-network hospital or ambulatory surgical center the mother’s or newborn’s attending provider, after consulting with the mother, When you get services from an in‑network hospital or ambulatory surgical from discharging the mother or her newborn earlier than 48 hours (or 96 hours center, certain providers there may be out‑of‑network. In these cases, the as applicable). In any case, plans and issuers may not, under Federal law, require most those providers may bill you is your plan’s in‑network cost‑sharing that a provider obtain authorization from the plan or the issuer for prescribing a amount. This applies to emergency medicine, anesthesia, pathology, radiology, length of stay not in excess of 48 hours (or 96 hours.) 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. 60