31 No Surprises Act The No Surprises Act (the “Act”) was signed into law in December 2020. The Act protects patients who receive emergency services at a hospital, at an independent freestanding emergency department, and from air ambulances. In addition, the law protects patients who receive emergency services from a Non- PPO Provider at an in-network facility. Effective January 1, 2022, beneficiaries receiving these services will only be responsible for paying their in-network cost sharing and cannot be billed for the balance by the provider or emergency services facility. Effective January 1, 2022, the Plan is implementing improvements to comply with the No Surprises Act. Emergency Services Emergency Services are covered: • Without the need for a prior authorization determination, even if the services are provided out-of- network; • Without regard to whether the health care provider furnishing the Emergency Services is a PPO Provider or a PPO emergency facility, as applicable, with respect to the services; • Without imposing any administrative requirements or limitations on out-of-network Emergency Services that are more restrictive than the requirements or limitations that apply to Emergency Services received from PPO Providers and PPO emergency facilities; • Without imposing cost sharing requirements on out-of-network Emergency Services that are greater than the requirements that would apply if the services were provided by a PPO Provider or a PPO emergency facility; • By calculating the cost sharing requirement for out-of-network Emergency Services as if the total amount that would have been charged for the services were equal to the Recognized Amount for the services; and • By counting any cost sharing payments made by the participant or beneficiary with respect to the Emergency Services toward any in-network deductible or in-network out-of-pocket maximums applied under the Plan (and the in-network deductible and in-network out-of-pocket maximums are applied) in the same manner as if the cost sharing payments were made with respect to Emergency Services furnished by a PPO Provider or a PPO emergency facility. Your cost sharing amount for Emergency Services from Non-PPO Providers will be based on the lesser of billed charges from the provider or the Qualified Payment Amount (“QPA”). Non-Emergency Items or Services from a Non-PPO Provider at a PPO Facility With regard to non-emergency items or services that are otherwise covered by the Plan, if the covered non-emergency items or services are performed by a Non-PPO Provider at a PPO facility, the items or services are covered by the Plan: • With a cost sharing requirement that is no greater than the cost sharing requirement that would apply if a PPO Provider had furnished the items or services. • By calculating the cost sharing requirements as if the total amount that would have been charged for the items and services by such PPO Provider were equal to the Recognized Amount for the items and services.