No Surprises Act Disclosure – Surprise Medical Bills

PA Center for Hearing and Balance is committed to complying with the federal No Surprises
Act and PA state regulations involving surprise billing and balance billing. This form contains
various disclosures pursuant to these laws.

Your rights and protections against surprise medical bills

When you are a private pay patient or get treated by an out-of-network provider, you are
protected from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you see us for your health care needs, especially if we are out-of-network with your health insurance plan, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible.

“Out-of-network” means that we have not signed a contract with your health plan to provide services.As a result, we may be allowed to bill you for the difference between what your plan pays and the fullamount we charge for a service. This is called “balance billing” and may result in a more expensive bill for you that also might not count toward your plan’s deductible or 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 surprise billing in certain circumstances:

• 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 to be balanced billed for these post-stabilization services. The No Surprises Act defines which types of services fall into these categories.
• Certain services at an in-network hospital or ambulatory surgical center. When you receive 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. You’re never required to give your consent. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
• Uninsured/Self-Pay Patients. Some provisions of the No Surprises Act are inapplicable to patients who are uninsured or who are self-pay. Instead, uninsured/self-pay patients are generally entitled to a “good faith estimate” for non-emergency services.

You are never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have these protections:

• You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network).
• Your health plan will pay any additional costs to out-of-network providers and facilities directly.
• Generally, your health plan must:

• Cover emergency services without requiring you to get approval for services in advance (also known as “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 in-network deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, first contact the provider that sent you the bill and your health plan for an explanation. If they can’t resolve your concerns or for more information, you can contact the

United States Department of Health and Human Services (https://www.coms.gov/nosurprises)
regarding the federal law. Email: FederalPPDRQuestions@cms.hhs.gov, or call 800-985-3059.
or the Pennsylvania Department of insurance (https://www.insurance.pa.gov/Consumers/insurance-complaint/Pages/default.aspx) or call them at 877-881-6388.