No Surprises Act Protections

• Emergency services: Plans must cover emergency services at in-network cost-sharing, regardless of provider network status
• Non-emergency services at in-network facilities: Plans must cover non-emergency services by out-of-network providers at in-network facilities at in-network cost-sharing (with notice and consent exceptions)
• Air ambulance services: Plans must cover air ambulance services at in-network cost-sharing
• Balance billing prohibition: Out-of-network providers cannot bill patients more than in-network cost-sharing for covered services

Independent Dispute Resolution

When a plan and an out-of-network provider cannot agree on payment, either party can initiate the IDR process. A certified IDR entity selects between the plan's offer and the provider's offer — it cannot split the difference. The IDR entity must consider the qualifying payment amount (QPA) and other factors. The losing party pays the IDR fee.

AEOB Status