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(OMB Control Number: 0938-1401)

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When you get emergency care or get treated by an out-of-network provider at an in-network hospital or
ambulatory surgical center, you are protected from surprise billing or balance billing.
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 a
copayment, 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 health care 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
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.

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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:
o Cover emergency services without requiring you to get approval for services in
advance (prior authorization).
o Cover emergency services by out-of-network providers.
o 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.
o Count any amount you pay for emergency services or out-of-network services toward
your deductible and out-of-pocket limit.

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If you believe you’ve been wrongly billed, you may contact the New York State Education
Department, Office of the Professions, at (518) 474-3817.

Visit
https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-pr
oviders-facilities-health.pdf for more information about your rights under Federal law.

Visit https://www.dfs.ny.gov/consumers/health_insurance/surprise_medical_bills for more information
about your rights under NYS law.

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