Part 2 – Explanation of Terms (continued) WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 10 Act, including items or services related to emergency medicine, anesthesiology, pathology, radiology and neonatology. This also includes services provided by assistant surgeons and diagnostic services.  Air ambulance services by a non-preferred air ambulance provider. For the covered services described above, the “recognized amount” will be used to calculate your cost share amount (deductible and/or copayment and/or coinsurance). The recognized amount is defined by federal law as: an amount determined by an applicable All-Payer Model Agreement under Section 1115A of the Social Security Act; or, if there is no applicable All-Payer Model Agreement, an amount determined by a specified state law where the services were furnished; or, if there is no applicable All-Payer Model Agreement or specified state law, the lesser of the amount billed by the provider or facility or the Qualified Payment Amount (QPA), which under the final rules generally is the median of the contracted rates of the plan or issuer for the item or service in the geographic region. For covered services furnished in Massachusetts, Blue Cross Blue Shield HMO Blue uses the QPA as the recognized amount to calculate your claim payment. For covered services furnished in a state other than Massachusetts, Blue Cross Blue Shield HMO Blue uses the applicable recognized amount that is provided by the local Blue Cross and/or Blue Shield Plan for that state to calculate your claim payment. Any cost share amounts that you pay for these covered services will count toward your in-network deductible (if applicable) and your out-of-pocket maximum. (If a non-preferred provider is dissatisfied with a payment made by the health plan, the provider can initiate a structured process to resolve the dispute. Federal law protects you from any payment disputes that may arise between plans and providers.) Note: The QPA will be used as the recognized amount to calculate your claim payment for covered air ambulance transport that is furnished by a non-preferred provider in or outside of Massachusetts. All Other Covered Services For all other covered services not described above that are not protected from surprise billing by the No Surprises Act, the allowed charge is based on 150% of the Medicare reimbursement rate. If there is no established Medicare reimbursement rate, the allowed charge is based on the amount determined by using current publicly-available data reflecting fees typically reimbursed for the covered service, adjusted for geographic differences. (There may be times when the Medicare reimbursement rate is not available for part of a claim for covered services. When this happens, the allowed charge will be based on the lesser of: the total of the Medicare reimbursement rate for the part for which there is a Medicare reimbursement rate plus the provider’s actual charge for the part for which there is no Medicare reimbursement rate; or the amount determined by using the current publicly-available data described above for all parts of the claim for the covered services.) Blue Cross Blue Shield HMO Blue has the discretion to determine what current publicly-available data it deems applicable, by using the data maintained by a third party of its choice. In no event will the allowed charge be more than the health care provider’s actual charge. However, the allowed charge may sometimes be less than the health care provider’s actual charge. If this is the case, you will be responsible for the amount of the covered provider’s actual charge that is in excess of the allowed charge. This is called “balance billing”. This is in addition to your deductible and/or your copayment and/or your coinsurance, whichever applies. For this reason, you may wish to discuss charges with your health care provider before you receive covered services. There are a few exceptions. This provision does not apply to ground ambulance transport for emergency medical care or covered services for which there is no established allowed charge (such as services received outside the