Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.
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, like a copayment, coinsurance, or deductible. You may have additional 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” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays 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 plan’s deductible or 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. Surprise medical bills could cost thousands of dollars depending on the procedure or service.
You’re 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 they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). 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. [Summary of any applicable state billing laws or requirements or state-developed language]
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 can 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 types of 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 protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.
[Insert plain language summary of any applicable state balance billing laws or requirements OR state-developed language regarding applicable state law requirements as appropriate]
When balance billing isn’t allowed, you also have these protections:
You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
Generally, your health plan must:
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.
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 in-network deductible and out-of-pocket limit.
If you think you’ve been wrongly billed, contact [Contact information for entity responsible for enforcing the federal and/or state balance or surprise billing protection laws. The federal phone number for information and complaints is: 1-800-985-3059].
Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law. Visit [Link to state website] for more information about your rights under [Name of state] laws. [If applicable, insert: Visit [website] for more information about your rights under [state laws].]
Good Faith Estimate
If you are uninsured or would like to pay out-of-pocket (otherwise known as "self-pay" or "private pay") for therapy sessions, you are entitled to a Good Faith Estimate (GFE).
Written notice will be provided in clear language that you can understand in an accessible format, and can be provided on paper or electronically, depending on your preference. Information will also be verbally provided when the service is scheduled or when you ask about costs, and available in accessible formats.
Your GFE will include:
Your name and date of birth.
A clear description of each item/service with diagnosis codes, expected service codes and expected charges associated with each listed item or service (and date of service if scheduled).
An itemized list of items/services reasonably expected to be furnished in conjunction with the primary item/service grouped by provider/facility along with the NPI/TIN and location of each.
Provider’s name, National Provider Identification (NPI) number, and Tax Identification Number (TIN) and office (s) where the items or services are expected to be furnished.
A disclaimer that the GFE is only an estimate of items/services reasonably expected to be furnished at the time and final items, services or charges may differ. (For recurring services, see “GFEs for Recurring Services”, below).
A disclaimer that additional recommended items or services may be part of the course of care but are not reflected in the GFE along with a separate list of items/services that require separate scheduling and for which separate GFEs would need to be requested.
A disclaimer informing you of your right to initiate the patient-provider dispute resolution (PPDR) process if the actual billed charges are substantially greater than the estimated charges along with instructions of where to find more information and written assurance that initiating such process will not adversely affect the quality of services rendered. (See “Disputes”, below).
A disclaimer that the estimate is not a contract and does not require you to obtain the items or services from any of the providers or facilities identified.
Timeframes:
Information regarding scheduled appointment will be provided within one (1) business day of scheduling an appointment to be provided in three (3) business days; and within three (3) business days of scheduling an appointment to be provided in at least 10 business days. A new GFE will be provided within the specified timeframes if you reschedule the requested appointment. If any information provided in the estimate changes, a new GFE will be provided no later than 1 business day before the scheduled care. Also, if there is a change in the expected provider less than one business day before the scheduled care, the replacement provider must accept the original GFE as their expected charges.
If we plan to meet in a recurring capacity (e.g., weekly therapy) the GFE will include, in a clear and understandable manner, the “expected scope of the recurring primary items or services (such as timeframes, frequency, and total number of recurring items or services)”. The GFE will only include recurring services that are expected to be provided within the next 12 months. For additional recurrences beyond 12 months, I will provide a new GFE and communicate any changes between the initial and the new estimates.
For example, if we expect that you will need continuing services throughout the year, the GFE could say: “I expect that my care of you will require continued weekly therapy sessions continuing through the end of the year, at $X per session for a total of 50 weeks, accounting for vacations and holidays for an estimated total of AMOUNT.”
If the future course of treatment is less certain, the GFE could say: “Depending on the progress we make this year, I expect that you will need 10–20 more sessions this year. At $X per session the estimated total cost would be AMOUNT.”
Disputes
Although the information provided in the GFE is only an estimate, and the actual items, services, or charges may differ from what is included in it, uninsured or self-pay individuals may challenge a bill from a provider through a new patient-provider dispute resolution (PPDR) process if the billed charges substantially exceed the expected charges in the GFE. “Substantially exceeds” means an amount that is at least $400 more than the expected charges listed on the GFE.