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:
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.
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.
You’re never required to give up your protection from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s 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 believe you’ve been wrongly billed, you may contact: www.cms.gov/nosurprises/consumers
Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf for more information about your rights under Federal law.
Good Faith Estimate
In compliance with the No Surprises Act that goes into effect January 1, 2022, all healthcare providers are required to notify clients of their federal rights and protections against “surprise billing”. This Act requires that we notify you of your federally protected rights to receive a notification when services are rendered by an out-of-network provider, if a client is uninsured, or if a client elects not to use their insurance.
Additionally, we are required to provide you with a Good Faith Estimate (GFE) of the cost of services. It is difficult to determine the true length of treatment for mental health care, and each client has a right to decide how long they would like to participate in mental health care. Therefore, below you will find a fee schedule for the services typically offered by your therapist, and they will collaborate with you on a regular basis to determine how many sessions you may need.
The below fees are meant to give you an idea of possible costs to keep you as much informed as possible. I will discuss fees prior to the start of treatment and provide GFE.
Some common codes I may use are:
90791: Therapy Intake Sessions
90837: Individual Therapy Session
90847: Couples/Family Intake Session
Your care is completely personalized. I do not believe that everyone needs a diagnosis to participate or benefit from therapy. I will only provide a diagnosis when appropriate. If you have questions about this, please contact me at firstname.lastname@example.org
Intake appointment & Follow-up appointments: $150
Client sees therapist weekly for 52 weeks in calendar year: $7,800
Client sees therapist every other week for 52 weeks: $3,900
Client sees therapist every 4 weeks for a year: $1,950