No Surprise Act

YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS
(OMB Control Number: 0938-1401)
(Updated 1.5.2022)
This notice is a requirement of the “No Surprises Law” and are providing this notification as required by the law. 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.

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-ofnetwork provider or facility, the most the provider or facility may bill you is your plan’s innetwork 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.

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. 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.
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 innetwork). 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.

Good Faith Estimate
Effective January 1, 2022, you have the right to receive a “good faith estimate” of what your services may cost.

The “No Surprises Act,” requires mental health practitioners to provide a “Good Faith Estimate” (GFE) about out-of-network care to any patient who is uninsured or who is insured but does not plan to use their insurance benefits to pay for health care items and/ or services.

At Lynsey Lomeli Counseling we provide good faith estimates as part of our onboarding process for new patients and before an initial appointment is scheduled.

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

A good faith estimate shows the costs of services that are reasonably expected for your mental health care needs for an item or service. The estimate is based on information known at the time the estimate was created. Please be advised, your fee may change depending on the number of sessions you actually attend. Services outside of standard therapy or assessment may have an associated extra cost.

We will provide you with a good faith estimate in writing at least 1 business day before your medical or mental health service or item.

You can also ask for a good faith estimate before you schedule a service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

For questions or more information about your right to a good faith estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-877-696-6775.