Rights and Protections Against Surprise Medical Bills

When you receive mental health or wellness care, you are protected from “surprise billing” or “balance billing” in certain situations.

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What Is “Balance Billing”? (Also Called “Surprise Billing”)

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When you see a therapist or other health care provider, you may owe certain out-of-pocket costs such as a copayment, coinsurance, or deductible. If you see a provider who is not in your health plan’s network, you may have to pay more or even the full bill.

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“Out-of-network” means the provider or facility has not signed a contract with your health plan. Out-of-network providers may bill you for the difference between what your plan pays and the full amount charged — this is called balance billing.

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“Surprise billing” happens when you cannot control who provides your care (for example, in an emergency or when an out-of-network provider participates in your treatment at an in-network facility without your knowledge).

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You Are Protected From Balance Billing For:

 

If you receive services at an in-network hospital, behavioral health clinic, or outpatient facility, some providers there may be out-of-network. In these cases, those providers may not bill you more than your plan’s in-network cost-sharing amount for services such as:

• Psychiatric evaluation

• Therapy (individual, group, or family)

• Psychological testing

• Medication management

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You cannot be asked to waive your balance billing protections for these services.

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You are never required to give up your protections from balance billing or to get care out-of-network. You can always choose a provider or facility within your plan’s network.

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When Balance Billing Isn’t Allowed, You Also Have These Protections:

• You are responsible only for paying your in-network share of the cost (copayments, coinsurance, and deductibles).

• Your health plan will pay out-of-network providers and facilities directly.

• Your health plan must:

  • Cover emergency services without requiring prior authorization.

  • Cover emergency services provided by out-of-network providers.

  • Base your cost-sharing on what it would pay an in-network provider.

  • Count any amount you pay toward your deductible and out-of-pocket limit.

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If you believe you’ve been wrongly billed or have questions about your bill, you may contact: Peace of Mind Mental Health Services, LLC
Administration: pomadmin@peaceofmindmhs.com

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You can also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS).
You must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the process.

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If the agency agrees with you, you will pay the amount listed in your Good Faith Estimate.

If they agree with the provider, you may have to pay the higher amount.

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Good Faith Estimate for Health Care Items and Services

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(Under the No Surprises Act)

Under Section 2799B-6 of the Public Health Service Act, health care providers must give clients who don’t have insurance or who aren’t using insurance a Good Faith Estimate of expected charges for therapy services.

If you are a client at Peace of Mind Mental Health Services, LLC who is uninsured or choosing not to use insurance, this information applies to you.

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About Your Good Faith Estimate

Your Good Faith Estimate will outline the expected costs of your mental health services (such as intake assessment, individual therapy, or group therapy sessions).

• The estimate is based on information available when it is created.

• It may change if your needs, frequency of sessions, or treatment plan changes.

• It does not include unexpected costs that could arise during care.

 

If your bill is $400 or more higher than your Good Faith Estimate, you have the right to dispute the bill.

You can:

• Ask your provider to update the bill to match the estimate.

• Ask to negotiate the bill.

• Ask if financial assistance is available.

• File a formal dispute through HHS within 120 days of receiving the bill.

 

To learn more or to start a dispute, visit: www.cms.gov/nosurprises

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The information above is adapted from the U.S. Centers for Medicare & Medicaid Services (CMS) Model Disclosure Notice and the American Psychological Association’s Good Faith Estimate Template.