YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS
UNDER THE “NO SURPRISES ACT OF 2021"
When you get emergency care or get treated by an out-of-network provider at an in-network hospi- tal or ambulatory surgical center and you did not choose that physician knowing they were out-of- network, you are protected from surprise billing or balance billing. This may apply to some service you receive as part of your care with NWEPS. It does not apply to NWEPS professional fees as we have previously disclosed to you that we are out-of-network providers.
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, such as a co- payment, coinsurance, and/or a deductible. You may 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 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 unexpect- edly treated by an out-of-network provider.
You are protected from balance billing for:
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 and give up your protections not to be balanced billed for these post-stabilization services.
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 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 and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
When balance billing isn’t 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.
If you believe you’ve been wrongly billed, you may contact:
* https://www.askebsa.dol.gov/WebIntake/?_ga=2.130152332.227126799.1640898562- 787594597.1636745697
For more information about your rights under Federal Law, go to:
* https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/no-surprises-act; or * https://www.cms.gov/nosurprises/consumers
Oregon State Law
Oregon maintains state law that essentially mirrors the rights and protections specified under federal law (the “No Surprises Act”), as described in this notice. Oregon’s rights and protections, however, do not relate to, among other types of plans:
* Employee welfare benefit plans governed by ERISA (and not the State of Oregon) (i.e., self-insured plans); * Medicare and Medicare supplement insurance policies; and
* Dental, vision, short-term benefit, and flexible spending plans.
For more information about your rights under Oregon State Law, go to:
* https://dfr.oregon.gov/news/2021/Pages/20211230-new-law-protects-consumers.aspx * https://dfr.oregon.gov/Documents/Surprise-billing-consumers.pdf
As NWEPS is a disclosed out of network provider, our bills are not surprise bills and therefor the protections of this act do not apply to our services. Under the details of this law, we require you to sign a disclosure that states that you have been notified that we are out of network and may balance bill you for unpaid portions of our bills. By signing this disclosure, you waive protection from balance billing provided by the "No Surprises Act of 2021". NWEPS does make routine write-downs, where allowed by law, to limit balance billing to the minimum possible. If you seek surgical care, you will be provided with a Good Faith Estimate of our billed charges for those services, as well as the out of pocket expenses you are expected to incur, prior to provision of that care.
Most patients that come to NWEPS do so because of our excellent reputation and skill set in endometriosis and complex pelvic pain care, knowing that we are out of network for their plan. Under the "No Surprises Act of 2021", we are legally required to disclose to you that there are alternate providers of gynecologic and gynecologic surgical care that may be within your insurance network. Within the city of Portland, the following are practices that offer advanced gynecologic surgery care:
Legacy Health Systems
Providence Health Systems
Pearl Women's Center
The Portland Clinic
Outside of the Portland area, if you choose you may consult your insurance company website to find a list of in-network gynecologic surgery providers.