Rates

(OMB Control Number: 0938-1401) 

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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.

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

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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.

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“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. 

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“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.

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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.

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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.

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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.

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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 co-payments, 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 by out-of-network providers.

  • Cover emergency services without requiring you to get approval for services in advance (priorauthorization).

  • 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 yourdeductible and out-of-pocket limit.
     

If you believe you’ve been wrongly billed, you may contact: Maryland Secretary of State at (410) 974-5521, Virginia Secretary of State at (804) 371-9967, or New Jersey Secretary of State at (609) 777-2581

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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.

 

STANDARD NOTICE “Right to Receive a Good Faith Estimate of Expected Charges” Under the No Surprises Act
 

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

 

Under the law, health care providers need to give patients who don’t have insurance or who are notusing insurance an estimate of the bill for medical items and services.

 You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes  related costs like medical tests, prescription drugs, equipment, and hospital fees.

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Make sure your health care provider gives you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your health care provider, and any other provider you choose for a Good Faith Estimate before you schedule an item or service. 

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Make sure your health care provider gives you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your health care provider, and any other provider you choose for a Good Faith Estimate before you schedule an item or service.

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If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. 

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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.

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Additionally, we are required to provide you with a Good Faith Estimate of the cost of services (attached). 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, (above) you will find a fee schedule for the services typically offered by your therapist, and we will collaborate with you on a regular basis to determine how many sessions you may need. 

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Make sure to save a copy or picture of your Good Faith Estimate.

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For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call (301) 244-8052.