Your Rights and Protections Against Surprise Medical Bills

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 isn’t in your health plan’s network.

“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. “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: 

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.

***Insight Therapy Group PC does not provide Emergency Services.

If you are choosing to see a provider who is in network with your insurance plan, you will be responsible for the cost share amount that your specific insurance plan has assigned. There will be no additional balances billed. Balance billing will not apply to you.

If you are choosing to see a provider who is out of network with your insurance plan, or if you do not have insurance or are choosing not to use your insurance, you will be responsible for the total balance of all services provided. In accordance with federal law, we can provide you with a Good Faith Estimate of what your cost share amount may be based on the services you plan to utilize with Insight Therapy Group PC.

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 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 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 care out-of-network. You can choose a provider or facility in your plan’s network.

***Insight Therapy Group PC does not provide hospital or ambulatory surgical services.

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 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 directly.
• 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 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 deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact the No Surprises Helpdesk at 1-800-985-3059.

Visit www.cms.gov/nosurprises for more information about your rights under federal law.