OMB Control Number: 0938-1401 Your Rights and Protections Against Surprise Medical Bills

There are new state and federal laws protecting patients from unwarranted healthcare billing - the Georgia Surprise Billing Consumer Protection Act and the federal No Surprises Act, which went into effect in January 2022 (but all subject to change). If you have any questions relating to the new regulations and your medical bills generated for our services, please call HyOx at 678-303-3200 and speak to one of our financial patient advocate team members. Please note, according to the Centers for Medicare and Medicaid, these requirements don’t apply to people with coverage through programs like Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE. These programs have other protections against high medical bills.

Surprise Billing – Your Rights and Protections Against Surprise Medical Bills

When you receive emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you have protection from surprise billing.

What is “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 also 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 a balance bill where a patient did not have notice that treatment was being rendered by an out-of-network provider. 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.

  If you are referred by HyOx to an out of network provider, you aren’t required to get care there and are encouraged to ask for another in-network referral. Under the law, the out-of-network physician/physician group is responsible for providing and obtaining any notice, consent, and disclosure if desired to bill at out-of-network rates in certain circumstances.

• 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 have the right to receive a good faith estimate for the total expected cost of non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.A good faith estimate is an estimate based on information known at the time with respect to anticipated non-emergency items/services. The good faith estimate is not a guarantee that your final costs will match the estimate. This means that the final cost of services may be different than this estimate. Final costs for which you are billed may vary for many reasons, among them are the patient’s medical condition, unknown circumstances or complications, final diagnosis, and recommended treatment ordered by the physician.

• Georgia State Protections. Many of the same protections afforded by the federal law are mirrored in the Georgia state law, but there are some key differences. The Georgia law only applies to self-insured employer health plans and government plans and is limited to services provided in Georgia. In addition to hospitals and ambulatory surgery centers, the Georgia law also applies to certain imaging centers, birthing centers, and similar facilities. Further, Georgia law has a different grievance process and disclosure requirements than the federal law. Definitions under the Georgia law and the federal law, although similar, may not be identical.

If balance billing isn’t allowed:

• 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 is required to pay providers and facilities directly.

• Your health/insurance plan generally must: cover emergency services without requiring approval 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; and count any amount you pay for emergency services or out-of-network services towards your deductive and out-of-pocket limit.

Surprise Billing – Your Grievance Rights

If you believe you’ve been wrongly billed, first contact the provider that sent you the bill and also 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.cms.gov/nosurprises) regarding the federal law or the Georgia Office of the Commissioner of Insurance and Fire Safety (https://oci.georgia.gov) or call 404.656.2070 regarding the Georgia law. The U.S. Centers for Medicare and Medicaid Services also has pertinent information on its site, https://www.cms.gov/nosurprises.