Common use of Protections from Unexpected Costs for Medical Services from Non-participating Providers Clause in Contracts

Protections from Unexpected Costs for Medical Services from Non-participating Providers. Your plan contains provisions related to protection from surprise balance billing under Texas law. The federal laws provide additional financial protections for You when You receive some types of care from Providers who do not participate in Your network. If You receive the types of care listed below, Your in- network cost-sharing levels will apply to any in-network out-of-pocket maximums. Additionally, for services below that are governed by federal law (instead of state law), Your cost-share amount may be calculated on an amount that generally represents the median payment rate that BCBSTX has negotiated with Participating Providers for similar services in the area. • emergency care from facilities or Providers who do not participate in Your network; and • care furnished by non-participating Providers during Your visit to a Participating facility; and • air ambulance services from non-Participating Providers, if the services would be covered with a Participating Provider. Non-participating Providers may not bill You for more than Your Copayment for these types of services. There are limited instances when a non-participating Provider of the care listed above may send You a bill for up to the amount of that Provider’s billed charges. You are only responsible for payment of the non- participating Provider’s billed charges if, in advance of receiving services, You signed a written notice form that complies with applicable state and/or federal law. The requirements of federal law that impact Your costs for care from non-participating Providers may not apply in all cases. Sometimes, Texas law provisions relating to balance billing prohibitions may apply. You may contact BCBSTX at the number on the back of Your identification card with questions about claims or bills You have received from Providers.