No Surprises Act Disclosure Notice

When you get emergency care or are treated by an out-of-network provider at an in-network facility, including a hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

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,like a copayment, coinsurance, or deductible. You may have additional 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” means providers and facilities that haven’t signed a contract with your healthplan to provide services. Out-of-network providers may be allowed to bill you for the differencebetween what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than innetwork costs for the same service and 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. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

You’re 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 they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). 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.

Please see below for information regarding California law.

Certain services at an in-network facility, including a hospital or ambulatory surgical center

When you get services from an in-network facility, including a hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can 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 protectionsnot to be balance billed. If you get other types of 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 outof-network care. You can choose a provider or facility in your plan’s network.

Please see below for information regarding California law.

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 inadvance (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 innetwork deductible and out-of-pocket limit.

California Law: California law generally contains balance billing protections similar to those under the No Surprises Act (as described in this Notice), except that the balance billing prohibitions also apply to services received in additional in-network facilities, including laboratories or radiology imaging centers. California also has an independent dispute resolution process to resolve claims-related issues, including disputes with your provider pertaining to receipt of improper balance bills, which can be initiated through the California Department of Insurance.

If you have a concern with how much you were billed on the service at our facility, please contact Customer Service at 925-947-3336 for assistance. You may also choose to contact the HHS No Surprises Helpdesk at 1- 800-985-3059, the entity responsible for enforcing the federal balance or surprise billing protection laws. Visit www.cms.gov/nosurprises/consumers for more information about your rights under federallaw.

For more information about your rights under California law, including how to initiate the dispute resolution process, contact the Department of Insurance Help Center online at http://www.insurance.ca.gov/01- consumers/101-help/index.cfm, or call 1-800-927-4357, the entity responsible for enforcing state balance or surprise billing protection laws.

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THIS COMMUNICATION IS NOT A BILL. YOU ARE NOT RESPONSIBLE FOR ANY PAYMENT TO YOUR PROVIDER UNTIL YOU RECEIVE INFORMATION FROM YOUR HEALTH PLAN OF ANY IN-NETWORK, COST-SHARING OBLIGATIONS YOU MAY HAVE. 

Your Right to Receive a “Good Faith Estimate” Explaining How Much Your Medical Care Will Cost

Effective 1/1/2022

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services, including related costs like medical tests, prescription drugs, equipment, and hospital fees.
  • Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item.
  • You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
  • Make sure to save a copy or picture of your Good Faith Estimate.
  • For questions or more information about your right to a Good Faith Estimate, visit http://www.cms.gov/nosurprises or call (800) 985-3059.