• Emergency air ambulance services
• Emergency facility/provider services
• Non-emergency services in connection to a visit to a facility
  

• Emergency room providers
• Anesthesiologists
• Pathologists
• Radiologists
• Neonatologists
• Assistant surgeons
• Hospitalists
• Intensivists
• Diagnostic services like radiology and laboratory *Advanced diagnostic laboratory tests are not included
• Other specialty items or services as identified by HHS
• Any service provided by an out-of-network provider if no in-network provider was available at the facility
• Urgent services that arise during a service for which Notice and Consent was provided
  

​Surprise billing protections apply if you get your coverage through:

• Your employer (including a federal, state, or local government)
• Our state-based Marketplace, Pennie
• Directly through an individual market health insurance company.
  

​Participants in the following plans do not have the balance billing protections:

• Indemnity or excepted benefit plan enrollees
• A plan that is not an "individual market" coverage plan
• A plan does not typically have a network
• Short-term limited duration plan enrollees
• Healthcare sharing ministry or Amish participants
• Individuals with no health care coverage at all
  

​Yes. An emergency is defined as a situation where a prudent person with average knowledge would reasonably expect that without immediate care, they would be placing in serious jeopardy, or serious impairment to bodily functions, or serious dysfunction of a bodily organ or part.

​No.  An emergency service may not be subject to prior authorization. There is no prior authorization allowed.

​No.  The service cannot be re-coded to a non-emergency based on the diagnosis code.

​Yes.  Providers, including Facilities (like hospitals, labs, and diagnostic centers) are required to post disclosures if they provide services at a Facility or in connection with a visit at a Facility.

The disclosures must be provided no later than when the Provider asks for payment or submits a claim to your Plan.

​Unless a Patient is very, very certain that they want that particular Provider to do the medical service, they should not sign the Notice and Consent.

The Notice and Consent must include very clear information; the Patient should make sure that they understand everything in it.

*If the Provider is one of the types of Providers who may never balance bill, the Patient is encouraged to immediately file a complaint.

No, a Notice and Consent must be a separate document.  It may not be included in another document or attached to another document.

The Notice and Consent must explain:

• That the Provider does not participate with the Patient's healthcare coverage plan (the Plan).
• The good faith estimated amount the Provider may charge the Patient for all services that would reasonably be included.
• Notice that the service might need to be authorized or otherwise approved by the Plan.
• Clearly state that signing the Notice is Optional; a Patient does not have to consent.
• Clearly state that the Patient may get the service from an available in-network Provider.
  

A Notice and Consent must be provided at least 72 hours (3 days) before a service is furnished.

If a service is scheduled within 3 days, the Notice must be given at least 3 hours ahead of time.

A Patient should not sign something they do not understand. The law and regulations require that the Notice be clear and understandable. The law also requires that a Patient may not be pressured into signing the Notice.

​Yes.  This can be done before the service is provided.