Self-Insured Notice

Insurance Notices

As part of its comprehensive benefits package for eligible employees, Meruelo Group LLC coordinates health insurance programs as a self-insured provider. The notices below apply to all participants in applicable insurance programs.

 

Transparency in Coverage Act

Effective July 1, 2022: The Transparency in Coverage (TIC) regulations require health insurers and group health plans to create machine-readable files (MRFs) that contain the negotiated rates for in-network providers and allowed amounts derived from historical claims for out-of-network providers, and make those files publicly available.
Visit https://www.anthem.com/machine-readable-file/search for more information.

 

No Surprises Act

Your rights and protections against surprise medical bills

 

When you receive emergency care or are treated by an out-of-network doctor or specialist at a hospital or ambulatory surgical center within your plan’s network, you are protected from surprise billing or balance billing.

 

What is “balance billing” (sometimes called “surprise billing”)?

When you visit a doctor or other healthcare specialist, you may owe certain out-of-pocket costs, such as a copay, coinsurance, and/or a deductible. If you visit a doctor, specialist, or healthcare facility that is not in your health plan’s network, you might owe additional charges or be responsible for the entire bill.

“Out-of-network” describes doctors and healthcare facilities that have not signed a contract with your health plan. Out-of-network doctors and facilities may bill you for the difference between what your 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 occur when you cannot control who is involved in your care, such as during an emergency or when you schedule a visit at a facility in your plan’s network but are unexpectedly treated by an out-of-network doctor.

 

You are protected from balance billing for:

 

Emergency services

If you have a medical emergency and receive care from an out-of-network doctor or facility, the most you can be billed is your plan’s in-network cost-sharing amount (such as copays and coinsurance). You cannot be balance billed for these emergency services. This protection includes care you may receive after you are in stable condition, unless you give written consent to waive your protections against balance billing once you are stable.

 

Certain services at a hospital or ambulatory surgical center in your plan’s network

When you receive services from a hospital or ambulatory surgical center (facilities that perform outpatient surgeries) in your plan’s network, some doctors or specialists there may be out-of-network. In these cases, the most they may bill you is your plan’s in-network cost-sharing amount. This applies to services in emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These specialists cannot balance bill you and cannot require you to give up your protections against balance billing.

If you receive other services at these in-network facilities, out-of-network doctors or other healthcare professionals cannot balance bill you unless you give written consent to waive your protections.

You are never required to give up your protections against balance billing. You are also not required to receive care outside your plan’s network. You can use the Find Care tool on our website to locate doctors and hospitals in your plan’s network.

 

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

  • You are only responsible for paying your share of the cost (such as copays, coinsurance, and deductibles that you would pay if the doctor or facility were in your plan’s network). Your health plan will pay out-of-network doctors and facilities directly.
  • Your health plan generally must:
    • Cover emergency services without requiring prior authorization.
    • Cover emergency services provided by out-of-network doctors or specialists.
    • Base your cost-sharing on what the plan would pay a doctor or facility in-network and show that amount in your explanation of benefits.
    • 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 can contact the Employee Benefits Security Administration (EBSA), the No Surprise Help Desk (NSHD) at 1-800-985-3059 or cms.gov/nosurprises, or your state regulator (if your plan is fully insured) to ask whether the charges are allowed by law.

**This notice was last updated August 1, 2024.