Moleculera Biosciences

No Surprises Act

Good Faith Estimate

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

MOLECULERA BIOSCIENCES IS OUT-OF-NETWORK WITH ALL INSURANCE CARRIERS.

The full cost of the Autoimmune Brain Panel™ (formerly known as the Cunningham Panel™) is $995 (within the contiguous United States). For patients outside the contiguous United States, please contact us at +1 (405) 239-5250 or via email at customerservice@moleculera.com for a Good Faith Estimate.

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing

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

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to 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 happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

State-Specific Rules

Some states have their own laws relating to balance or surprise billing for out-of-network laboratory services that may be different from those described by the No Surprises Act. The links below contain state specific balance billing information and resources, including contact information for state agencies that may be able to help you further.

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network.

When balance billing isn’t allowed, you also have the following protections:

You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (prior authorization).
- Cover emergency services by out-of-network providers.
- 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.
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you think you’ve been wrongly billed: you may file a complaint with the federal government at https://www.cms.gov/nosurprises/consumers or by calling 1-800-985-3059; and/or file a complaint with your state balance billing regulator, if any, which is identified in the state-specific tabs.

Visit https://www.cms.gov/nosurprises for more information about your rights under federal law or visit your home state regulator’s website (included in state links above) for more information about your state balance billing rights.

ARIZONA RESIDENTS

ARIZONA LAW MAY PROVIDE PROTECTIONS TO YOU AND ALLOW MOLECULERA TO BILL YOU FOR AMOUNTS THAT ARE DIFFERENT FROM THOSE PROVIDED BY THE FEDERAL LAW AS DESCRIBED IN YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLING

FOR MORE INFORMATION REGARDING YOUR PROTECTIONS AGAINST SURPRISE BILLING, CONTACT OR VISIT:

Arizona Department of Insurance and Financial Institutions
Address: 100 N. 15th Ave. Ste. 261, Phoenix, AZ 85007-2630
Phone: (602) 364-3100
E-mail: soonbdr@azinsurance.gov
Website: https://difi.az.gov/soonbdr

CALIFORNIA RESIDENTS

CALIFORNIA LAW MAY PROVIDE PROTECTIONS TO YOU AND ALLOW MOLECULERA TO BILL YOU FOR AMOUNTS THAT ARE DIFFERENT FROM THOSE PROVIDED BY THE FEDERAL LAW AS DESCRIBED IN YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLING