Part 2 – Explanation of Terms (continued) WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 9 Blue Cross and/or Blue Shield Plan in the area where services are received. In addition, some local Blue Cross and/or Blue Shield Plans’ payment agreements with providers do not give a comparable discount for all claims. These local Blue Cross and/or Blue Shield Plans elect to smooth out the effect of their payment agreements with providers by applying an average discount to claims. The price that reflects average savings may result in greater variation (more or less) from the actual price paid than will the estimated price. Local Blue Cross and/or Blue Shield Plans that use these estimated or averaging methods to calculate the negotiated price may prospectively adjust their estimated or average prices to correct for overestimating or underestimating past prices. However, the amount you pay is considered a final price. In most cases for covered services furnished by these health care providers, you pay only your deductible and/or your copayment and/or your coinsurance, whichever applies. Value-Based Provider Arrangements: A provider’s payment agreement with a local Blue Cross and/or Blue Shield Plan may include: a payment arrangement based on health outcomes; and/or coordination of care features. Under these payment agreements, the providers will be assessed against cost and quality standards. Payments to these providers may include provider incentives, risk sharing, and/or care coordination fees. If you receive covered services from such a provider, you will not have to pay any cost share for these fees, except when a local Blue Cross and/or Blue Shield Plan passes these fees to Blue Cross Blue Shield HMO Blue through average pricing or fee schedule adjustments for claims for covered services. When this happens, you pay only your deductible and/or your copayment and/or your coinsurance, whichever applies.  For Other Health Care Providers. For covered health care providers who do not have a PPO payment agreement with Blue Cross Blue Shield HMO Blue or for health care providers outside of Massachusetts who do not have a payment agreement with the local Blue Cross and/or Blue Shield Plan, Blue Cross Blue Shield HMO Blue will use the methods outlined below to calculate your claim payment. Patient Protections Against Surprise Billing Under federal law, you are protected from “balance billing” or “surprise billing” (an unexpected balance bill) in certain situations. Under the law, you cannot be balance billed for certain covered services that you may receive. But, for these covered services, you will continue to be responsible for any copayment, deductible and/or coinsurance, whichever applies. You cannot be balance billed when you receive:  Emergency services. This includes: emergency services you receive at an emergency room of a hospital or an independent free-standing emergency facility; and certain covered services that may be required to stabilize you (post-stabilization services) until such time that your attending physician determines you meet certain criteria as outlined under federal law. When you become stabilized and any notice and consent requirements as specified in the statute are met, surprise billing protection no longer applies. See “All Other Covered Services” below for how your claim payment will be calculated when this happens.  Non-emergency services furnished by a non-preferred provider at certain preferred facilities. This includes services you receive at: a hospital; a hospital outpatient department; a critical access hospital; an ambulatory surgical center; or any other facility designated by the statute that provides items or services for which coverage is provided under this health plan unless the notice and consent requirements as specified in the statute have been met. A provider or facility cannot provide notice and receive consent for certain ancillary services, as defined by the No Surprises