1 Consolidated Appropriations Act of 2021 Notice Consolidated Appropriations Act of 2021 (CAA) The Consolidated Appropriations Act of 2021 (CAA) is a Federal law that includes the No Surprises Act as well the Provider transparency requirements that are described below. Surprise Billing Claims Surprise Billing Claims are claims that are subject to the Federal No Surprises Billing Act requirements: • Emergency Services provided by Out-of-Network Providers; • Covered Services provided by an Out-of-Network Provider at an In-Network Facility; and • Out-of-Network Air Ambulance Services. No Surprises Act Requirements Emergency Services As required by the CAA, Emergency Services are covered under your Plan: • Without the need for Precertification; • Whether the Provider is In-Network or Out-of-Network; If the Emergency Services you receive are provided by an Out-of-Network Provider, Covered Services will be processed at the In-Network benefit level. Note that if you receive Emergency Services from an Out-of-Network Provide, your out-of-pocket costs will be limited to amounts that would apply if the Covered Services had been furnished by an In-Network Provider. However, Out-of-Network cost shares (i.e., Copayments, Deductibles and/or Coinsurance) will apply to your claim if the treating Out-of-Network Provider determines you are stable, meaning you have been provided necessary Emergency Care such that your condition will not materially worsen and the Out-of-Network Provider determines: (i) that you are able to travel to an In-Network Facility by non- emergency transport; (ii) the Out-of-Network Provider complies with the notice and consent requirement; and (iii) you are in condition to receive the information and provide informed consent. If you continue to receive services from the Out-of-Network Provider after you are stabilized, you will be responsible for the Out-of-Network cost shares, and the Out-of-Network Provider will also be able to charge you any difference between the Maximum Allowed Amount and the Out-of-Network Provider’s billed charges. This notice and consent exception does not apply if the Covered Services furnished by an Out-of-Network Provider result from unforeseen and urgent medical needs arising at the time of service. Out-of-Network Services Provided at an In-Network Facility When you receive Covered Services from an Out-of-Network Provider at an In-Network Facility, your out- of-pocket costs will be limited to amounts that would apply if the Covered Service had been furnished by an In-Network Provider. However, if the Out-of-Network Provider gives you proper notice of its charges, and you give written consent to such charges, claims will not be covered. This means you will be responsible for Out-of-Network cost shares for those services and the Out-of-Network Provider can also charge you any difference between the Maximum Allowed Amount and the Out-of-Network Provider’s billed charges. This Notice and Consent process described below does not apply to Ancillary Services furnished by an Out-of-Network Provider at an In-Network Facility. Your out-of-pocket costs for claims for Covered Ancillary Services furnished by an Out-of-Network Provider at an In-Network Facility will be limited to amounts that would apply if the Covered Service had been furnished by an In-Network Provider. Ancillary Services are one of the following services: (A) Emergency Services; (B)