Good Faith Estimates & No Surprises Billing Act
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 should not 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, have to pay the entire bill if you see a provider, or visit a health care facility that is not in your health plan’s network. “Out-of-network” means providers and facilities that have not 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 cannot 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 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 they can bill you is your plan’s in-network cost sharing amount (such as copayments, coinsurance, and deductibles). You cannot 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 balance 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 can bill you is your plan’s innetwork cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers cannot 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 cannot balance bill you, unless you give written consent and give up your protections. You are never required to give up your protections from balance billing. You also are not required to get out-of-network care. You can choose a provider or facility in your plan’s network.
When balance billing is not allowed, you also have these protections: • You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility were in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly. • Generally, your health plan must: o 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. o Base what you owe the provider or facility (cost sharing) on what it would pay an innetwork provider or facility and show that amount in your explanation of benefits. o Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.
Here is an example for counseling services with Joey Pickering, LMHC:
Each session is billed at $150/hour. For self-pay clients there is the option of a cash discount or sliding scale. How long you engage in counseling services is up to you. If you use insurance, your copay/coinsurance and deductible will determine your personal cost.
EXAMPLE 1: You've met your insurance deductible and now just have $20 copays per visit. You've attended 6 sessions.
Billed to insurance: CPT 90837 $150 x 6 = $900
Insurance pays: $100 x 6 = $600
CoPays client is responsible for: $20 x 6 = $120
Balance left over: $180 <--- this is written off; patient not responsible.
EXAMPLE 2: You are paying out of pocket with a sliding scale rate of $115/session. You've attended 6 sessions.
CPT 90837 $115 x 6 = $690
Balance due: $690
A personalized Good Faith Estimate can be created for you upon request.