© Joseph R. Lee 2024
NO SURPRISES ACT DISCLOSURE NOTICE
YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS
(OMB Control Number: 0938-1401)
You are protected from surprise billing or balance billing when you get emergency care or are treated by an out-of-network provider at an in-network
hospital or ambulatory surgical center.
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 copayments, 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 healthcare 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.
Certain services at an in-network hospital or ambulatory surgical center
Certain providers may be out-of-network when you get services from an in-network hospital or ambulatory surgical center. 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 were in-network). Your health plan will pay out-of-network providers and facilities
•
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
•
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
•
Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket
If you believe you’ve been wrongly billed, you may contact the No Surprises Help Desk at 1-800-985-3059 from 8 am to 8 pm EST, 7 days a week, or
submit a complaint online at https://www.cms.gov/nosurprises/consumers. Visit https://www.cms.gov/files/document/model-disclosure-notice-
patient-protections-against-surprise-billing-providers-facilities-health.pdf for more information about your rights under Federal law.
© Joseph R. Lee 2013
NO SURPRISES ACT DISCLOSURE NOTICE
YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS
(OMB Control Number: 0938-1401)
You are protected from surprise billing or balance billing when you get emergency care or are treated by an out-of-network provider at an in-network
hospital or ambulatory surgical center.
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 copayments, 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 healthcare 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.
Certain services at an in-network hospital or ambulatory surgical center
Certain providers may be out-of-network when you get services from an in-network hospital or ambulatory surgical center. 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 were in-network). Your health plan will pay out-of-network providers and facilities
•
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
•
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
•
Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket
If you believe you’ve been wrongly billed, you may contact the No Surprises Help Desk at 1-800-985-3059 from 8 am to 8 pm EST, 7 days a week, or
submit a complaint online at https://www.cms.gov/nosurprises/consumers. Visit https://www.cms.gov/files/document/model-disclosure-notice-
patient-protections-against-surprise-billing-providers-facilities-health.pdf for more information about your rights under Federal law.