no surprises act
Overview
Effective January 1, 2022, the No Surprises Act (which Congress passed as part of the Consolidated Appropriations Act of 2021) is designed to protect clients from surprise bills for emergency services at out-of-network facilities or for out-of-network providers at in-network facilities, holding them liable only for in-network cost-sharing amounts. The No Surprises Act also enables uninsured clients to receive a good faith estimate of the cost of care.
When you get emergency care or receive services by an out-of-network provider at an in-network facility, you are protected from surprise billing sometimes called, balance billing.
When you see a 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.
“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 seen by an out-of-network provider.
Consumer Notice
Requiring out-of-network providers to provide any potential clients with notice that they are outside of the client’s health plan’s network, is a large part of the No Surprises Act’s purpose. Any potential client can waive paying out-of-network prices for non-emergency services so long as they consent.
For out-of-network clients, they will be given notice within seventy-hours of the scheduled appointment. At their request, the notice can be provided in paper or electronic format, as you prefer. The form will clearly state:
· The provider is out-of-network;
· An estimate of the cost of services (which we will calculate in good faith) called a good faith estimate.
This document will be separate from all other documents you sign prior to care.
You are never required to give up your protections from surprise billing. You also are not required to get out-of-network care. You can choose a provider in your plan’s network.
Lastly, there is a requirement which states that out-of-network providers must notify health plans when they provide a client service, and they must certify that they have met the required notice and consent requirements. These records will be maintained for a minimum of seven years.
If You Think You Have Been Wrongly Billed or Have More Questions
If you think you have been wrongly billed or are uncertain whether the No Surprises Act applies to you or if you have any additional questions about standard notice forms or the No Surprises Act in general, reach out to Art with Grace Counseling at (541) 954-6494.
Complaints
If you still feel you have been wrongly billed, you may contact The Oregon Board of Licensed Professional Counselors and Therapists: 503.378.5499 or lpct.board@mhra.oregon.gov
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.
Visit https://www.oregon.gov/oblpct/pages/index.aspx for more information about your rights under the state of Oregon.
Effective January 1, 2022, the No Surprises Act (which Congress passed as part of the Consolidated Appropriations Act of 2021) is designed to protect clients from surprise bills for emergency services at out-of-network facilities or for out-of-network providers at in-network facilities, holding them liable only for in-network cost-sharing amounts. The No Surprises Act also enables uninsured clients to receive a good faith estimate of the cost of care.
When you get emergency care or receive services by an out-of-network provider at an in-network facility, you are protected from surprise billing sometimes called, balance billing.
When you see a 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.
“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 seen by an out-of-network provider.
Consumer Notice
Requiring out-of-network providers to provide any potential clients with notice that they are outside of the client’s health plan’s network, is a large part of the No Surprises Act’s purpose. Any potential client can waive paying out-of-network prices for non-emergency services so long as they consent.
For out-of-network clients, they will be given notice within seventy-hours of the scheduled appointment. At their request, the notice can be provided in paper or electronic format, as you prefer. The form will clearly state:
· The provider is out-of-network;
· An estimate of the cost of services (which we will calculate in good faith) called a good faith estimate.
This document will be separate from all other documents you sign prior to care.
You are never required to give up your protections from surprise billing. You also are not required to get out-of-network care. You can choose a provider in your plan’s network.
Lastly, there is a requirement which states that out-of-network providers must notify health plans when they provide a client service, and they must certify that they have met the required notice and consent requirements. These records will be maintained for a minimum of seven years.
If You Think You Have Been Wrongly Billed or Have More Questions
If you think you have been wrongly billed or are uncertain whether the No Surprises Act applies to you or if you have any additional questions about standard notice forms or the No Surprises Act in general, reach out to Art with Grace Counseling at (541) 954-6494.
Complaints
If you still feel you have been wrongly billed, you may contact The Oregon Board of Licensed Professional Counselors and Therapists: 503.378.5499 or lpct.board@mhra.oregon.gov
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.
Visit https://www.oregon.gov/oblpct/pages/index.aspx for more information about your rights under the state of Oregon.
Grace Fletcher, ATR, LPC * 541.954.6494 * Grace@ArtwithGraceCounseling.com * Copyright © 2024
390 Lincoln Street, Suite 240 Eugene, Oregon 97401
390 Lincoln Street, Suite 240 Eugene, Oregon 97401