network providers and facilities directly. • Generally, your health plan must: o Cover emergency services without requiring you to get approval for services in advance (also known as “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 in-network deductible and out-of-pocket limit. If you think you’ve been wrongly billed, contact your insurance carrier by calling the number on your insurance card. You may also contact your state insurance regulator or the No Surprises helpdesk at 1-800-985-3059. Visit www.cms.gov/nosurprises/consumersfor more information about your rights under federal law. Patient Protection Notice Your health insurance carrier may require or allow the designation of a primary care provider. You have the right to designate any primary care provider who participates in your network and who is available to accept you or your family members. Until you make this designation, your carrier may designate one for you. For children, you may designate a pediatrician as the primary care provider. For information on how to select a primary care provider, and for a list of participating primary care providers, contact the Plan Administrator at 603-594-6171. You do not need prior authorization from your health insurance carrier or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in your network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the Plan Administrator at 603-594-6171. . Requesting Documentation of Mental Health and Substance Use Disorder Treatment Coverage Criteria and Limitations Under a federal law called the Mental Health Parity and Addiction Equity Act (MHPAEA), health plans and insurers must make sure that there is “parity” between mental health and substance use disorder (MH/SUD) benefits, and medical and surgical benefits. This generally means that financial requirements and treatment limitations applied to MH/SUD benefits cannot be more restrictive than the financial requirements and treatment limitations applied to medical and surgical benefits. You are entitled to • General information about treatment limitations, like your plan’s preauthorization policies for both medical/surgical and MH/SUD treatment, and your plan’s criteria for determining medical necessity. • Specific information about why benefits were denied. For example, you can ask about the criteria for “failure to show medical necessity” that your health insurance company may have used to deny your claim. In addition, health plans and insurers that offer coverage that provides both medical/surgical benefits and MH/SUD benefits, and that imposes non-quantitative treatment limitations (NQTLs), must analyze how any NQTLs are designed and applied. Plan participants and beneficiaries are entitled to a copy of this comparative analysis upon request.