HEALTH PLAN NOTICES FOR BENEFITS ELIGIBLE EMPLOYEES YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS (CONTINUED) 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 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 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 Centers for Medicare & Medicaid Services https://www.cms.gov/nosurprises. https://www.cms.gov/nosurprises/Policies-and-Resources/Overview-of-rules-fact-sheets for more information about your rights under federal law. Visit