Noblesville Schools Medical Plan 35 Schedule of Benefits Set 001 Allowed Amounts are determined in accordance with the Claims Administrator's reimbursement policy guidelines, or as required by law, as described in the SPD. Designated Network Benefits and Network Benefits Allowed Amounts are based on the following: • When Covered Health Care Services are received from a Designated Network and Network provider, Allowed Amounts are our contracted fee(s) with that provider. • When Covered Health Care Services are received from an out-of-Network provider as arranged by the Claims Administrator, including when there is no Network provider who is reasonably accessible or available to provide Covered Health Care Services, Allowed Amounts are an amount negotiated by the Claims Administrator or an amount permitted by law. Please contact the Claims Administrator if you are billed for amounts in excess of your applicable Coinsurance, Copayment or any deductible. The Plan will not pay excessive charges or amounts you are not legally obligated to pay. 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 Health Service Act with respect to a visit as defined by the Secretary (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 below 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, "certain Network facilities" are limited to a hospital (as defined in 1861(e) of the Social Security Act), a hospital outpatient department, a critical access hospital (as defined in 1861(mm)(1) of the Social Security Act), an ambulatory surgical center as described in section 1833(i)(1)(A) of the Social Security Act, and any other facility specified by the Secretary. 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 Copayment, Coinsurance or deductible which is based on the Recognized Amount as defined in the 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 below 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).