Your Rights and Protections Against Surprise Medical Bills under the No Surprises Act

What Sidecar Health Plans does this notice apply to?
This notice applies to Sidecar Health Major Medical Insurance Plans purchased by You or provided to You by Your Employer.

This notice does not apply to Sidecar Health Access Plans.

What is “balance billing” (sometimes called “surprise billing”)?
When You see a doctor or other health care provider, You may owe certain out-of-pocket costs, called cost-sharing. Under Your Sidecar Health Plan, the only cost-sharing is Your Deductible. You may have other costs if You see a Provider or visit a health care facility that charges above Your plan’s Benefit Amount, which is the amount Your plan pays for a particular service. Please see Your Plan details at www.sidecarhealth.com to review Your applicable Deductible or see the Benefit Amount for a particular service.

Traditional health plans contract with providers to create “networks.” When You utilize an in-network provider, Your plan covers the cost. However, if You receive care from an out-of-network provider, You may be billed for the amount the provider charges over what the plan is willing to pay them. “Out-of-network,” or “non-participating,” means providers and facilities that haven’t signed a contract with Your health plan.

Out-of-network providers may be permitted to bill You for the difference between what Your Plan pays and the full amount charged for a service. This is called “balance billing.” “Surprise billing” is an unexpected balance bill. This can happen when You cannot control which providers are involved in Your care—like when You have an emergency.

Unlike traditional health plans, Sidecar Health allows You to see any Provider You wish. Sidecar Health does not have contracts with any Providers or facilities, and thus, all Providers and facilities could be considered “out-of-network,” “non-participating,” or “non-network” for purposes of balance billing and surprise billing. Because the benefits Sidecar Health pays are fixed and may be less than a provider’s charge, a provider may send You a bill for any charges remaining after We pay You the applicable Benefit Amount. This is balance billing. Typically, We cannot prohibit a provider from billing You the difference between the provider’s charge for a Covered Service and the applicable Benefit Amount.

However, in the event You receive covered emergency services, Sidecar Health will work with Providers and the facility who coordinate Your emergency to eliminate “Surprise Billing” over the Benefit Amount. You are protected by the No Surprises Act from having to cover the cost of those additional charges.

You are protected from balance billing and surprising billing for Emergency services.

If You have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill You is Your Plan’s deductible. You can’t be balance billed for these emergency services. This includes charges for services You may incur after You’re in stable condition, unless You give written consent and give up Your protections not to be balanced billed for these post-stabilization services.

You are never required to give up Your protections from balance billing. As a reminder, through Your Sidecar Health Plan, You can choose any Provider or facility to receive care, and can view the Benefit Amount for Your care at www.sidecarhealth.com or by calling Member Care at 1-877-553-8246. You aren’t required to get care from a Provider or facility that charges more than the Benefit Amount. Typically, if You choose to see a Provider who charges more than the Benefit Amount, the additional cost is billed to You.

In Emergency Situations, when balance billing isn’t allowed, as described above, You also have the following protections:

• You are only responsible for paying Your share of the cost (i.e., Your Deductible). Your health plan will pay “out-of-network” providers and facilities directly.
• Your health plan generally must:
  • Cover emergency services without requiring You to get approval for services in advance (prior authorization).
  • Cover emergency services by out-of-network providers.
  • Base what You owe the Provider or facility (cost-sharing) on what it would pay an in‑network provider or facility and show that amount in Your explanation of benefits. In the case of Sidecar Health, this is the Benefit Amount.
  • Count any amount You pay for emergency services or out-of-network services toward Your Deductible and out-of-pocket limit.

If You believe You’ve been wrongly billed and have self-funded insurance through Your employer, You may contact the Department of Health and Human Services No Surprises Helpdesk at 1-800-985-3059.

Visit https://www.cms.gov/nosurprises for more information about Your rights under Federal law.

If You believe You’ve been wrongly billed and have fully-insured insurance purchased in Ohio either individually or through Your employer, You may also contact the Ohio Department of Insurance at 1-800-686-1526 for assistance with surprise billing.