Protection from balance bills for surprise and emergency services. This notice explains how you can get help with unexpected bills from out-of-network providers. This applies to members enrolled in health plans subject to New York regulations. Check your plan documents for more details on balance bills. You can also call Member Services at the toll-free number on your ID card.

About surprise bills.

1. What is a New York Surprise Bill? It’s a bill you receive for the below covered services: • Services performed by an out-of-network physician at a participating hospital or

ambulatory surgical center, when:

(i) A participating physician is unavailable at the time the health care services are performed; (ii) An out-of-network physician performs the services without your knowledge; or (iii) Unforeseen medical issues or services arise at the time the health care services are performed.

• You may also receive a surprise bill if you were referred by a participating physician to an out-of-network provider without your explicit written consent, acknowledging that the referral is to an out-of-network provider and may result in costs not covered by us. For a surprise bill, a referral to an out-of-network provider means:

(i) Covered services are performed by an out-of-network provider in the participating physician’s office or practice during the same visit; (ii) The participating physician sends a specimen taken from you in the participating physician’s office to an out-of-network laboratory or pathologist; or (iii) For any other covered services performed by an out-of-network provider at the participating physician’s request, when referrals are required by your plan. Your plan documents list when referrals are needed.

2. When it’s not a surprise bill. When a participating physician is available, and you chose to receive services from an out-of-network physician.

3. Tell us if you had a New York Surprise Bill. Complete the New York Assignment of Benefits form if you got a surprise balance bill. The form is: • Attached to this notice • On the New York Department of Financial Services website at DFS.NY.Gov • On Aetna.com under our state-specific legal notices

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4. How to send us send an Assignment of Benefits Form. 1. Through your member website:

(i) Log in to your secure member w ebsite at Aetna.com. (ii) Click “Contact Us” in upper right corner. (iii) Attach your form and bill. (iv) Click submit.

2. Mail it to us on the Aetna address on your ID card

3. Mail it to us at: Aetna Member Correspondence Unit PO Box 981106 El Paso, Texas 79998-1106

5. Tell your provider this is a New York surprise bill. Send a copy of your Assignment of Benefits form to your provider. This alerts the office not to bill you over your in-network cost share.

6. What happens after Aetna gets my Assignment of Benefits Form? • We’ll review the balance over your network cost share (copayment, deductible or

coinsurance). • We will send you an Explanation of Benefits (EOB) if we pay more to the provider. It

will tell you if you owe more cost share. • If we don’t settle, the provider may file a fee dispute called Independent Dispute

Resolution (IDR).

Emergency services. You only need to pay your network cost share for emergency services. Your plan documents explain how emergency services are defined. Follow the steps in item four above if you get a balance bill over your network cost share for emergency services. We’ll handle it following the benefits in your plan documents.

Out-of-network hospital bills when you’re admitted after an emergency room visit. New York amended its law on January 1, 2020 to expand balance billing protections to inpatient services provided by a physician or hospital following an emergency-room visit at an out-of-network hospital.

You can also use the Assignment of Benefits form to send us your balance bill for these services. The form is attached to this notice.

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Independent Dispute Resolution Process (IDR). Certain fee disputes can be sent to the New York IDR process.

IDR for Surprise Bills • We or a provider may file IDR. • The IDR application is on the New York Department of Financial Services website,

DFS.NY.Gov. • The process starts by completing an IDR application and sending it to the New York

Department of Financial Services. • The IDR will be reviewed by a state-assigned independent dispute resolution entity

(IDRE). • The IDRE will decide if our payment or the provider’s fee is more reasonable within

30 days of receiving the IDR application. • If we need to pay more to the provider, your cost share may go up. • A member of a self-funded health plan or a patient who does not have insurance may

also file IDR on their own.

IDR for emergency Services • New York has provided IDR for emergency physician services since March 31, 2015. • New York amended its IDR law on January 1, 2020 to expand IDR eligibility to:

(a) emergency services provided by an out-of-network hospital; and (b) inpatient services provided by a physician or hospital following an emergency-room visit at an out-of-network hospital.

• We or the provider can file IDR following the same steps noted above. • A member of a self-funded plan or a patient who does not have insurance may also

file IDR on their own. • IDR is for emergency services performed in New York. • If you get a balance bill for emergency services outside of New York, you can also

send it to us for review. Upon receipt, we’ll handle it based upon the benefits of your health plan.

Health benefits and health insurance plans are offered and/or underwritten by Aetna Life Insurance Company and/or Aetna Health Insurance Company of New York (Aetna). Each insurer has sole financial responsibility for its own products.

©2020 Aetna Inc. 00.03.763.1-NY A (8/20)

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State Out-of-Network Emergency and Surprise Medical Bill Assignment of Benefits Form Use this form if you get a surprise medical bill or a bill for out-of-network emergency services and want the services to be treated as in-network. This form is used to protect consumers from certain surprise bills for health care services and out-of-network emergency charges, including inpatient services following an emergency room visit. Please note: This form is NOT required for out-of-network emergency services, but provides protection from bills for such services.

To use this form, complete and sign it. A copy must be sent to your health care provider and your insurer (include a copy of any bill you received for these services).

Use this form when: • You received a bill for services from a non-participating physician at a participating hospital or ambulatory surgical

center, where a participating physician was not available; a non-participating physician provided services without your knowledge; or unforeseen medical circumstances happened when the services were provided. You did not choose to receive services from a non-participating physician instead of from an available participating physician.

• You received a bill for services for which you were referred by a participating physician to a non-participating provider, but you did not sign a written consent that you knew the services would be out-of-network and result in costs not covered by your insurer. A referral occurs: (1) during a visit with your participating physician, a non-participating provider treats you; or (2) your participating physician takes a specimen from you in the office and sends it to a non-participating laboratory or pathologist; or (3) for any other health care services when referrals are required under your plan.

• You received emergency services from an out-of-network hospital or doctor, including inpatient services following an emergency room visit.

I assign my rights to payment to my provider and I certify to the best of my knowledge that: I (or my dependent) received emergency services, inpatient services following an emergency room visit, or a surprise bill from a provider. I want the provider to seek payment for this bill from my insurance company (this is an “assignment”). I want my insurer to pay the provider for any health care services I or my dependent received that are covered under my health insurance. With my assignment, the provider cannot seek payment from me, except for any in-network copayment, coinsurance or deductible that I owe. If my insurer paid me for the services, I agree to send the payment to the provider. Patient Name: Date of Service:

Patient Mailing Address: Patient City/State/ZIP:

Insurer Name: Insurance ID No:

Provider Name: Provider Phone Number:

Provider Mailing Address: Provider City/State/ZIP:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation.

(Signature of patient) (Date of signature)

If you have questions regarding this form contact the Department of Financial Services at 1-800-342-3736. NYS FORM OON-AOB (7/22/20)

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Aetna complies with applicable federal civil rights laws and does not unlawfully discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability.

We provide free aids/services to people with disabilities and to people who need language assistance. If you need a qualified interpreter, written information in other formats, translation or other services, call the number on your ID card. If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting: Civil Rights Coordinator,P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779), 1-800-648-7817, TTY: 711, Fax: 859-425-3379 (CA HMO customers: 860-262-7705). You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).

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TTY:711

English To access language services at no cost to you, call the number on your ID card.

Albanian Për shërbime përkthimi falas për ju, telefononi në numrin që gjendet në kartën tuaj të identitetit.

Amharic የ ቋን ቋ አ ገ ልግሎቶችን ያ ለ ክፍያ ለ ማግኘት፣ በ መታወቂያ ዎት ላይ ያ ለ ውን ቁጥር ይደውሉ፡ ፡ Arabic

Armenian Ձեր նախընտրած լեզվով ավվճար խորհրդատվություն ստանալու համար զանգահարեք ձեր բժշկական ապահովագրության քարտի վրա նշված հէրախոսահամարով

Bantu-Kirundi Kugira uronke serivisi z'indimi ata kiguzi, hamagara inomero iri ku karangamuntu kawe

Bengali

Burmese

Catalan Per accedir a serveis lingüístics sense cap cost per a vostè, telefoni al número ŮƇīŮġēt ē ƀē sįvē tēršįtē ī’ŮīįƇtŮĹŮġēġŮſ.

Cebuano Aron maakses ang mga serbisyo sa lengguwahe nga wala kay bayran, tawagi ang numero nga anaa sa imong kard sa ID.

Chamorro Para un hago' i setbision lengguåhi ni dibåtde para hågu, ågang i numiru gi iyo-mu kard aidentifikasion.

Cherokee ᏩᎩᏍᏗ ᎦᏬᏂᎯᏍᏗ ᎢᏅᎾᏓᏛᏁᏗ Ꮭ ᎪᎱᏍᏗ ᏗᏣᎬᏩᎳᏁᏗ ᏱᎩ, ᏫᎨᎯᏏᎳᏛᏏ ᎾᏍᎩ ᏗᏎᏍᏗ ᏥᏕᎪᏪᎵ ᎤᎾᎢ ID ᏆᏂᏲᏍᏗ ᏣᏤᎵᎢ.

Chinese Traditional 如欲使用免費語言服務，請撥打您健康保險卡上所列的電話號碼

Choctaw Anumpa tosholi i toksvli ya peh pilla ho ish i payahinla kvt chi holisso kallo iskitini holhtena takanli ma i payah

Chuukese Ren omw kopwe angei aninisin eman chon awewei (ese kamé), kopwe kééri ewe nampa mei mak won noum ena katen ID

Cushitic-Oromo Tajaajiiloota afaanii gatii bilisaa ati argaachuuf,lakkoofsa fuula waraaqaa eenyummaa (ID) kee irraa jiruun bilbili.

Dutch Voor gratis taaldiensten, bel het nummer op uw ziekteverzekeringskaart.

French Pour accéder gratuitement aux services linguistiques, veuillez composer le numéro indiqué sur votre carte d'assurance santé.

French Creole (Haitian)

Pou ou jwenn sèvis gratis nan lang ou, rele nimewo telefòn ki sou kat idantifikasyon asirans sante ou.

German Um auf den für Sie kostenlosen Sprachservice auf Deutsch zuzugreifen, rufen Sie die Nummer auf Ihrer ID-Karte an.

Greek Για πρόσβαση στις υπηρεσίες γλώσσας χωρίς χρέωση, καλέστε τον αριθμό στην κάρτα ασφάλισής σας.

Gujarati

Hawaiian No ka walaʻau ʻana me ka lawelawe ʻōlelo e kahea aku i ka helu kelepona ma kāu kāleka ID. Kāki ʻole ʻia kēia kōkua nei.

Hindi

Hmong Yuav kom tau kev pab txhais lus tsis muaj nqi them rau koj, hu tus naj npawb ntawm koj daim npav ID.

Igbo Inweta enyemaka asụsụ na akwughi ụgwọ obụla, kpọọ nọmba nọ na kaadi njirimara gị

Ilocano Tapno maakses dagiti serbisio ti pagsasao nga awanan ti bayadna, awagan ti numero nga adda ayan ti ID kardmo.

Indonesian Untuk mengakses layanan bahasa tanpa dikenakan biaya, silakan hubungi nomor telepon di kartu asuransi Anda.

Italian Per accedere ai servizi linguistici senza alcun costo per lei, chiami il numero sulla tessera identificativa.

Japanese 無料の言語サービスは、 IDカードにある番号にお電話ください。

Karen

Korean 무료 다국어 서비스를 이용하려면 보험 ID 카드에 수록된 번호로 전화해

주십시오.

Kru-Bassa I nyuu kosna mahola ni language services ngui nsaa wogui wo, sebel i nsinga i ye ntilga i kat yong matibla

Kurdish

Lao

Marathi

Marshallese Ņan bōk jipan̄ kōn kajin ilo an ejjeļọk wōņean n̄an kwe, kwōn kallok nōṃba eo ilo kaat in ID eo aṃ.

Micronesian-Ponapean

Pwehn alehdi sawas en lokaia kan ni sohte pweipwei, koahlih nempe nan amhw doaropwe en ID.

Mon-Khmer, Cambodian

Navajo

Nepali

Nilotic-Dinka Të kɔɔr yïn ran de wɛɛ̈r̈ de thokic ke cïn wëu kɔr keek tënɔŋ yïn. Ke yïn cɔl ran ye kɔc kuɔny në namba de abac tɔ̈ në ID kard duɔ̈n de tïït de nyin de panakim kɔ̈u.

Norwegian For tilgang til kostnadsfri språktjenester, ring nummeret på ID-kortet ditt.

Pennsylvanian-Dutch Um Schprooch Services zu griege mitaus Koscht, ruff die Nummer uff dei ID Kaart.

Persian Farsi .برای دسترسی بە خدمات زبان بە طور رايگان، با شماره قید شده روی کارت شناسايی خود تماس بگیريد

Polish Aby uzyskać dostęp do bezpłatnych usług językowych, należy zadzwonić pod numer podany na karcie identyfikacyjnej.

Portuguese Para aceder aos serviços linguísticos gratuitamente, ligue para o número indicado no seu cartão de identificação.

Punjabi

Romanian Pentru a accesa gratuit serviciile de limbă, apelați numărul de pe cardul de membru.

Russian Для того чтобы бесплатно получить помощь переводчика, позвоните по телефону, приведенному на вашей идентификационной карте.

Samoan Mō le mauaina o 'au'aunaga tau gagana e aunoa ma se totogi, vala'au le numera i luga o lau pepa ID.

Serbo-Croatian Za besplatne prevodilačke usluge pozovite broj naveden na Vašoj identifikacionoj kartici.

Spanish Para acceder a los servicios lingüísticos sin costo alguno, llame al número que figura en su tarjeta de identificación.

Sudanic Fulfulde Heeɓa a naasta nder ekkitol jaangirde woldeji walla yoɓugo, ewnu lamba je ɗon windi ha do ɗerowol maaɗa.

Swahili Kupata huduma za lugha bila malipo kwako, piga nambari iliyo kwenye kadi yako ya kitambulisho.

Syriac-Assyrian

Tagalog Upang ma-access ang mga serbisyo sa wika nang walang bayad, tawagan ang numero sa iyong ID card.

Telugu

Thai

Tongan Kapau ‘oku ke fiema’u ta’etōtōngi ‘a e ngaahi sēvesi kotoa pē he ngaahi lea kotoa, telefoni ki he fika ‘oku hā atu ‘i ho’o ID kaati.

Turkish Dil hizmetlerine ücretsiz olarak erişmek için kimlik kartınızdaki numarayı arayın.

Ukrainian Щоб безкоштовнź отримати мовні послуги, задзвоніть за номером, вказаним на вашій ідентифікайній картці.

Urdu کارڈ پر درج نمبر پر کال ID اپنے بیمہ کے کے لیے، ُ مفت رسائی لسانی خدمات تککریں۔

Vietnamese Để sử dụng các dịch vụ ngôn ngữ miễn phí, vui lòng gọi số điện thoại ghi trên thẻ ID của quý vị.

Yiddish צו באקומען שפראך סערוויסעס פריי פון אפצאל, רופט דעם נומער אויף איי ער ID קארטל.Yoruba Láti ráyèsí àwọn iṣẹ́ èdè fún ọ lọ́fẹ̀ẹ́, pe nọ́mbà tó wà lórí káàdì ìdánimọ̀ rẹ.