No Surprise Act Disclosure

 

Arrowhead Orthopaedics is committed to helping you navigate through the new Federal law, the No Surprises Act, and the following disclosure is provided for your information.

No Surprise Billing: Your Rights and Protections Against Surprise Medical Bills

 

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, have to pay the entire bill if you see a provider, or visit a health care facility that is not in your health plan’s network.

“Out-of-network” describes providers and facilities that have not 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 cannot control who is involved in your care—an emergency or when you schedule a visit at an innetwork 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 innetwork cost-sharing amount (such as copayments and coinsurance). You cannot be balance billed for these emergency services. This includes services you may get after you are in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

California state law has similar protections to the federal No Surprises Act.

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 cannot 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 cannot balance bill you, unless you give written consent and give up your protections.

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

When balance billing is not 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:

  • Cover emergency services without requiring you to get approval for services in advance (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

    deductible and out-of-pocket limit.

 

Your Grievance Rights

If you believe your bill is incorrect, first contact our Business Office at (909) 557-1600 and reference your statement to our representative. You can also email us at billing@arrowheadortho.com. If our office does not satisfactorily respond to your issue, you may contact the Centers for Medicare and Medicaid Services at CMS at www.cms.gov for your rights under federal law.

 

For more information about your rights under California state law visit California Department of Managed Health Care at www.dmhc.ca.gov or California Department of Insurance at www.insurance.ca.gov.