Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
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, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in the AFL-CIO Health & Welfare Fund’s (the Plan’s) network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with the Plan’s network provider. Out-of-network providers may be permitted to bill you for the difference between what the Plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance 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 the Plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get 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.
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is the Plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist (hospital services), or intensivist services (intensive/critical care services). These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in the Plan’s network.
When balance billing isn’t allowed, you also have the following protections:
- You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). The Plan will pay out-of-network providers and facilities directly.
- The Plan generally must:
o Cover emergency services without requiring you to get approval for services in advance (prior authorization).
o Cover emergency services by out-of-network providers.
o 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.
o 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, you may contact the Fund Office at 1-800-996-0592 or the Centers for Medicare and Medicaid Services (CMS) No Surprises Helpdesk at 1-800-985-3059.
Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.
Benefits Update
As recently announced, the AFL-CIO Health and Welfare Fund (the “Fund”) has made a few updates to its health care benefits for participants who receive coverage through United Healthcare. Two Fund Trustees briefly describe these updates in the video linked below.
Please note that the “Retail 90” and “Preventive Vaccinations” updates described in the video apply only to participants who are not enrolled in the Fund’s MedicareRx coverage. All updates are effective January 1, 2020.
If you have any questions about these benefits, or whether they apply to you, please call the Fund Administrator at 1-877-423-5246, or refer to the detailed summary mailed to you in December 2019.
Real Appeal
UnitedHealthcare (UHC) has provided the following information about Real Appeal:
We all want to live a healthy life. Though each of us may have different goals for our health, taking simple steps in the right direction leads to positive life changes and helps us to achieve these goals. This is why we are offering Real Appeal, a free and convenient 52-week online weight-loss program that is designed to solve the typical barriers to managing your health.
Real Appeal helps you lose weight and reduce your risk of developing certain diseases like diabetes and cardiovascular disease as it’s based on decades of proven clinical research. Most Real Appeal participants lose an average of 10 pounds after completing only four sessions of the program.
When you enroll, you receive:
• 52 weeks of access to a Transformation Coach. Your coach guides you through the program and develops a simple, customized plan that fits your needs, preferences and goals.
• 24/7 access to digital tools and dashboards that help you track your food, activity and weight.
• A success kit full of healthy weight management tools including fitness guides, a recipe book (with quick family meal ideas and fast-food eating tips), weight scale and more.
• Support from weekly online group classes to learn healthy ideas from your Coach and other Real Appeal participants who share what’s helped them achieve success.
Real Appeal strives to inspire its participants to find the strength, the belief and the trust that change is in every one of us. If you’re ready to spark your transformation, visit aflciohealthplan.realappeal.com to learn more and join today.
*Real Appeal is available to eligible participants covered under the AFL-CIO Health & Welfare Plan in a UHC program (including eligible spouses and dependents 18 or over) with a BMI of 23 or higher. There is no cost to the participant for Real Appeal participation. Real Appeal is not available to Medicare eligible participants.