HEALTH PLAN NOTICES You are protected from balance billing for: health plan generally must: Your Emergency services - If you have an emergency medical condition and get  Cover emergency services without requiring you to get approval for services emergency services from an out-of-network provider or facility, the most the in advance (prior authorization). provider or facility may bill you is your plan’s in-network cost-sharing amount  Cover emergency services by out-of-network providers. (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  Base what you owe the provider or facility (cost-sharing) on what it would condition, unless you give written consent and give up your protections not pay an in-network provider or facility and show that amount in your to be balanced billed for these post-stabilization services. explanation of benefits. Certain services at an in-network hospital or ambulatory surgical center -  Count any amount you pay for emergency services or out-of-network When you get services from an in-network hospital or ambulatory surgical services toward your deductible and out-of-pocket limit. center, certain providers there may be out-of-network. In these cases, the If you believe you’ve been wrongly billed, you may contact the Centers for most those providers may bill you is your plan’s in-network cost-sharing Medicare & Medicaid Services https://www.cms.gov/nosurprises amount. This applies to emergency medicine, anesthesia, pathology, Visit https://www.cms.gov/nosurprises/Policies-and-Resources/Overview-of- radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist rules-fact-sheets for more information about your rights under federal law. 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. 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.