Federal No Surprises Act

• Self-funded health benefit plans, including state government and municipal health benefit plans
• Fully insured health benefit plans
• Federal Employees Health Benefit Plan (FEHBP)
• Grandfathered health plans

If you are not sure what type of plan you have, call us at the number on your ID card. We’re here to help.

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 must 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 allowed 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. Examples are 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 only responsible for paying your share of the cost, such as 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.
• You’re never required to give up your protections from balance billing. You also don’t have to get care out-of-network. You can choose a provider or facility in your plan’s network.

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 the provider or facility may bill you is your plan’s in-network cost-sharing amount. This includes copayments, deductibles and coinsurance. You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition. The exception is if you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services performed by an out-of-network provider at an in-network hospital or ambulatory surgical center

When you get services from certain out-of-network providers at an in-network hospital or ambulatory surgical center, those out-of-network providers may not balance bill you or ask you to sign a written notice and consent form that allows balance billing. You pay only your plan’s in-network cost-sharing amount. This applies to anesthesia, assistant surgeon, emergency medicine, hospitalist, intensivist service, laboratory, neonatology, pathology, or radiology.

If you get other services from any other out-of-network providers at in an in-network hospital or ambulatory surgical center, these out-of-network providers can’t balance bill you, unless you sign a written notice and consent form that allows balance billing and are provided with a good faith estimate of your costs from the hospital or ambulatory surgical center before services are given. If you sign the notice and consent form, you can be balance billed for out-of-network services. You are not required to sign the notice and consent form. You may seek care from an available in-network provider.

Air ambulance

When you receive medically necessary air ambulance services from an out-of-network provider, your cost share will be the same amount that you would pay if the service was provided by an in-network provider. Any coinsurance or deductible will be based on rates that would apply if the services were supplied by an in-network provider.

Some states have surprise bill/balance billing laws. These laws apply to fully insured plans and may have impact to some self-funded plans, including state government or municipal plans and church plans. Check with your plan administrator and/or booklet to find if state law applies to your coverage.

In general, your health plan 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.

If you think you’ve been wrongly billed, information and resources are available to you.  

Get help by phone

You can send complaints about potential violations of federal law or state law to the U.S. Department of Health & Human Services at 1-800-985-3059.

Get help online

You can also visit the Centers for Medicare & Medicaid Services website to learn about federal guidance to end surprise bills and find help from your state agency.

Are you undergoing a course of treatment from a facility or provider for a serious and complex condition or a terminal illness? Are you undergoing a course of institutional or inpatient care? Are you scheduled to undergo nonelective surgery, including post-operative care? Are you pregnant and undergoing treatment from the facility or a provider? Then you may be eligible to continue your care at the facility or with the provider at your in-network benefit level for a period of time.

You can either get a Transition Coverage Request form on our Secure Member Website or you can call Member Services using the number on your ID card. Ask Member Services to send you a Transition Coverage Request form. Both you and your provider need to complete the form and send it to us. You have 90 days from the date you received this letter to send the completed form for us to consider your request.

If you relied on inaccurate information from our provider directories or website or that we verbally provided, we hold you harmless. For example, if you received services from a provider that you believed was in-network based on inaccurate information showing that the provider was in-network, but your claim was paid as out-of-network. In these situations, contact us — we’re here to help. The number is on the back of your ID card. We will review the claim. After review, you may be responsible only for your in-network cost share.

Provider obligations under the No Surprises Act.

Providers and health care facilities must generally:

• Refund enrollees amounts paid in excess of in-network cost-sharing amounts with interest, if the enrollee has inadvertently received out-of-network care due to inaccurate provider directory information, the provider or facility billed the enrollee for an amount in excess of in-network cost-sharing amounts, and the enrollee paid the bill.
• Maintain business processes to submit provider directory information at specified times to support plans and issuers in maintaining accurate, up to date provider directories.

Aetna complies with applicable federal civil rights laws and does not unlawfully discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability.

We provide free aids and services to people with disabilities and to people who need language assistance.

If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card. If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting:

Civil Rights Coordinator

P.O. Box 14462

Lexington, KY 40512

CA HMO customers:

PO Box 24030

Fresno, CA 93779

Phone: 1-800-648-7817 (TTY: 711)

Fax: 859-425-3379 (CA HMO customers: 1-860-262-7705).

You can also file a civil rights complaint with the U.S. Department of Health and Human Services Office, Office for Civil Rights Complaint Portal or at:

U.S. Department of Health and Human Services

200 Independence Avenue SW.

Room 509F, HHH Building

Washington, DC 20201

Phone: 1-800-368-1019 or 1-800-537-7697 (TDD).