OUT-OF-NETWORK BENEFITS When covered health care services are received from an Out-of-Network provider as described below, allowed amounts are determined as follows: • For non-Emergency covered health care services received at certain network facilities from Out-of- Network Physicians when such services are either Ancillary Services or non-Ancillary Services that have not satisfied the notice and consent criteria of section 2799B-2(d) of the Public Service Act with respect to a visit as defined by the Secretary of Health and Human Services (including non-Ancillary Services that have satisfied the notice and consent criteria but unforeseen, urgent medical needs arise at the time the services are provided), the allowed amount is based on one of the following, in the order listed as applicable: ➢ The reimbursement rate as determined by a state All Payer Model Agreement. ➢ The reimbursement rate as determined by state law. ➢ The initial payment made by the claims administrator, or the amount subsequently agreed to by the Out-of-Network provider and the claims administrator. ➢ The amount determined by Independent Dispute Resolution (IDR). For the purpose of this provision, the term "certain network facility" is limited to a Hospital, a Hospital Outpatient department, a critical access Hospital, an ambulatory surgical center, and any other facility specified by the Secretary of Health and Human Services. IMPORTANT NOTICE: For Ancillary Services, non-Ancillary Services provided without notice and consent, and non-Ancillary Services for unforeseen or urgent medical needs that arise at the time a service is provided for which notice and consent has been satisfied, You are not responsible, and an Out- of-Network Physician may not bill You, for amounts in excess of Your applicable Co-pay, Plan Participation, or Deductible, based on the Recognized Amount as defined in this SPD. • For Emergency health care services provided by an Out-of-Network provider, the allowed amount is based on one of the following, in the order listed as applicable: ➢ The reimbursement rate as determined by a state All Payer Model Agreement. ➢ The reimbursement rate as determined by state law. ➢ The initial payment made by the claims administrator, or the amount subsequently agreed to by the Out-of-Network provider and the claims administrator. ➢ The amount determined by Independent Dispute Resolution (IDR). IMPORTANT NOTICE: You are not responsible, and an Out-of-Network provider may not bill You, for amounts in excess of Your applicable Co-pay, Plan Participation, or Deductible, based on the Recognized Amount as defined in this SPD. • For air Ambulance Transportation provided by an Out-of-Network provider, the allowed amount is based on one of the following, in the order listed as applicable: ➢ The reimbursement rate as determined by a state All Payer Model Agreement. ➢ The reimbursement rate as determined by state law. ➢ The initial payment made by the claims administrator, or the amount subsequently agreed to by the Out-of-Network provider and the claims administrator. ➢ The amount determined by Independent Dispute Resolution (IDR). IMPORTANT NOTICE: You are not responsible, and an Out-of-Network provider may not bill You, for amounts in excess of Your Co-pay, Plan Participation, or Deductible, based on the rates that would have applied if the service had been provided by a network provider and on the Recognized Amount as defined in this SPD. After the Plan has issued payment for covered health care services, the Plan may be required to pay the provider an additional amount or discount to resolve and settle the provider’s balance bill. -54- 7670-00-413597