No Surprises Act

Your Rights and Protections Against Surprise Medical Bills

The federal “No Surprises Act” grants consumers the right to receive a “Good Faith Estimate” explaining how much their medical and mental health care will cost. Under the law, health care providers, including psychotherapists, must give clients who don’t have insurance or who are not using insurance an estimate of the expected charges for treatment services.

WHAT IS A “SURPRISE BILL?”

• Surprise bills happen when an out-of-network provider treats you at an in-network hospital or ambulatory surgical center OR you are referred by an in-network doctor to an out-of-network provider.
• In-network: Means the provider participates with your health plan’s network.
• Out-of-network: Means the provider has not signed a contract or is not credentialed 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: Also referred to as “surprise 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.

IT’S A SURPRISE BILL WHEN YOUR IN-NETWORK DOCTOR REFERS YOU TO AN OUT-OF-NETWORK PROVIDER IF:

• You did not sign a written consent that you knew the services were out-of-network and would not be covered by your health plan; AND
• During a visit with your participating doctor, a non-participating provider treats you; OR
• Your in-network doctor takes a specimen from you in the office (for example, blood) and sends it to an out-of-network laboratory or
  pathologist; OR
• For any other health care services when referrals are required under your plan.

IF YOU GET A SURPRISE BILL BECAUSE AN OUT-OF-NETWORK PROVIDER TREATS YOU AT AN IN-NETWORK HOSPITAL OR AMBULATORY SURGICAL CENTER OR YOUR DOCTOR REFERS YOU TO AN OUT-OF-NETWORK PROVIDER:

• You are only required to pay your in-network cost-sharing.
• If an out-of-network provider bills you for any amount over your in-network cost-sharing (copayment, coinsurance, or deductible) this is
  balance-billing.
• If your doctor referred you to an out-of-network provider, you MUST send a Surprise Bill Certification Form to your health plan and your
  provider to make sure that they know you received a Surprise Bill and that you must be protected from balance billing.
• You may also file a complaint with DFS.

HOW TO PROTECT YOURSELF FROM A SURPRISE MEDICAL BILL IF YOU ARE UNINSURED – GOOD FAITH ESTIMATE FOR UNINSURED OR SELF-PAY PATIENTS

• If you are uninsured, or you are insured but you don’t plan to file a claim with your health plan, health care providers must give you a good
  faith estimate of what their expected charges will be before you get health care services. If after getting your bill you realize that any of your providers or facilities billed you for an amount that’s $400 or more than what’s on your good faith estimate, you can use a new dispute resolution process to request that an independent third-party, called a dispute resolution entity, review your case, and determine an appropriate payment.

Providers must give you the good faith estimate:

• For services scheduled at least 3 business days ahead of time, within 1 business day of scheduling the service;
• For services scheduled at least 10 business days ahead of time, within 3 business days of scheduling the service; or
• When you ask for the good faith estimate, within 3 business days of you asking for the estimate.

The good faith estimate will include:

• A description of the service you will be getting;
• A list of other services that are reasonably expected to be provided with the service you are getting;
• The diagnosis and expected service codes; and
• The expected charges for the services.

ilearn wellness group’s Commitment to Transparency

• Ilearn wellness group is committed to transparency. Typically, out of network care costs the insured more than in-network care; so, we make our best effort to verify patient eligibility and provider participation prior to rendering services. To ensure affordable access to quality behavioral healthcare, we honor fixed rates for our uninsured, self-pay and out-of-network patients.