NO SURPRISES ACT: 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 healthcare facility that isnʼt in your health plan network.
“Out-of-network” describes providers and facilities that havenʼt 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 planʼs in-network cost-sharing amount (such as copayments and coinsurance). You canʼt be balance billed for these emergency services. This includes services you may get after you are 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 may be out of network. In these cases, the most those providers may bill you is your planʼs in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers canʼt 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 canʼt balance bill you unless you give written consent and give up your protections.
You are never required to give up your protection from balance billing. You also arenʼt required to get care out-of-network. You can choose a provider or facility in your plan network.
When balance billing isnʼt 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
- 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
- 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
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket
GOOD FAITH ESTIMATE FROM Dallas Counseling, PLLC and/or Justin K. Hughes, MA, LPC
Dallas Counseling, PLLC, and Justin K. Hughes, MA, LPC are out-of-network with insurance. The patient is responsible for all fees for service at the time service is rendered, as outlined in the Informed Consent and Practice Policies.
Although it is impossible to determine in advance precisely how many sessions each patient will need to achieve their treatment goals, most patients need an average of 16-20 weeks of consistent, regularly scheduled sessions–with active independent practice between sessions to achieve a significant treatment response. Patients with more severe symptoms, who have had symptoms for many years, have multiple conditions (e.g., OCD and Major Depression; Panic Disorder and Social Anxiety Disorder), and/or cannot commit to regular sessions or consistent practice, can expect to need more frequent and longer treatment. Hourly rates, as outlined in the Informed Consent & Privacy Practices, are charged as sessions are scheduled. These rates are, in effect, your good faith estimate for any session or service you choose to schedule. These rates will not change unless such a change is fully discussed and agreed upon by the patient and provider. An example of when the fee may change is if a session is scheduled for 55 minutes and the patient has had a crisis or, for any reason, needs more time in a session, and the provider can extend the session to 90 minutes on short notice. This option to extend the service time will be discussed before a session continues and services are provided, and the additional fee will be discussed before the first instance where time is extended. To keep up with inflation and market prices and to maintain provider salaries commensurate with experience, providers must occasionally raise rates of service. Notice of any increase in fees for service will be provided at least one month in advance in writing, and changes to this agreement will be confirmed by the patient’s signature.
The Good Faith Estimate is not a contract between provider and client and does not obligate or require the client to obtain any of the listed services from the provider. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call HHS at (800) 985-3059.
If you believe you have been wrongly billed, you may contact The Texas Secretary of Stateʼs Office: https://www.sos.state.tx.us/
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.