PAI | Privacy and Legal

Discrimination is Against the Law

Planned Administrators, Inc. (PAI) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex (consistent with the scope of sex discrimination under Section 1557 of the Patient Protection and Affordable Care Act). We do not exclude people or treat them less favorably because of race, color, national origin, age, disability, or sex.

We provide people with disabilities reasonable modifications and free appropriate auxiliary aids and services to communicate effectively with us, such as:

Qualified sign language interpreters
Written information in other formats (large print, audio, accessible electronic formats, other formats).

We provide free language assistance services to people whose primary language is not English, which may include:

Qualified interpreters
Information written in other languages.

If you need reasonable modifications, appropriate auxiliary aids and services, or language assistance services, contact our Section 1557 Coordinator at 1-800-832-9686 or by emailing Section1557Coordinator@hcrcompliance.com.

If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by emailing Section1557Coordinator@hcrcompliance.com or by calling 1-800-832-9686. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, email Section1557Coordinator@hcrcompliance.com and assistance will be provided.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW Room 509F, HHH Building

Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

This notice is available at PAI’s website: https://www.paisc.com.

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When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

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, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays 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 plan’s deductible or 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 they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in a 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 can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist 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 types of 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 are never required to give up your protections from balance billing. You also are not required to get out-of-network care. You can choose a provider or facility in your plan’s network.

When balance billing is not allowed, you also have these protections:

n You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly. n Generally, your health plan must:

- - Cover emergency services without requiring you to get approval for services in advance (also known as “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.
  - Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

If you think you’ve been wrongly billed, First contact PAI’s Customer Service Team at 1 (800)768-4375 or at www.paisc.com. We will review your claim(s) with you to determine if it is your true member cost-share. If not, and the provider is billing you for covered services that are not true member-cost share based on the recognized/allowable amount, we will work with your provider to negotiate one. After thirty (30) days we are unable to agree on a recognized/allowable amount, you can contact the Employee Benefits Security Administration at 1-866-444-EBSA(3272) for group health plans that are subject to ERISA, or the Department of Health and Human Services at 1-888-393-2789 for group health plans that are not subject to ERISA. The federal phone number for information and complaints is: 1-800-985-3059.

First contact PAI’s Customer Service Team at 1(800)768-4375 or at www.paisc.com.

You may also receive help through an applicable state consumer assistance program. Visit https://www. dol.gov/sites/default/files/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/ consumer-assistance-programs.doc for contact information by state.

Visit https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/no-surprises-act for more information about your rights under federal law.