Your Rights and Protections Against Surprise Medical Bills
This form is modified from the model form provided by the US Department of Health and Hospitals.
Federal and State legislation protects you from surprise billing and balance billing when you get emergency care or get treated by an out-of-network provider at an in-network facility. Engage Psychotherapy LCSW, PLLC, is not an in-network provider with any insurance payor so the majority of this legislation does not apply to our services, but it is important to understand the protections provided in legislation and where they do and do not apply to our services.
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 health care facility that isn’t in your health plan’s network.
Engage Psychotherapy is an “Out-of-network” provider, which means we have not signed contracts with any health insurance plans. 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. This occurs commonly at hospitals, which may involve a mixture of in and out-of-network providers. However, surprise billing as defined in legislation does not occur at Engage Psychotherapy because you have direct control over who is involved in your care (i.e. your therapist) and psychotherapy session fees are discussed and agreed upon at outset.
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.
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 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.
Under existing legislation, Engage Psychotherapy is allowed to balance-bill since we are not contracted with any insurance plans. We charge you an agreed fee for our services and you are responsible for payment for either the full fee or, if your insurance company will pay us directly as an out-of-network provider, the portion of the session fee that insurance does not cover. However, if you are seeing a provider at a facility where balance billing isn’t allowed, you have the following protections:
If you believe you’ve been wrongly billed, you may contact the NYS Dep of Financial Services.
Visit https://www.dfs.ny.gov/consumers/health_insurance/surprise_medical_bills for more information about your rights under federal law.
Federal and State legislation protects you from surprise billing and balance billing when you get emergency care or get treated by an out-of-network provider at an in-network facility. Engage Psychotherapy LCSW, PLLC, is not an in-network provider with any insurance payor so the majority of this legislation does not apply to our services, but it is important to understand the protections provided in legislation and where they do and do not apply to our services.
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 health care facility that isn’t in your health plan’s network.
Engage Psychotherapy is an “Out-of-network” provider, which means we have not signed contracts with any health insurance plans. 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. This occurs commonly at hospitals, which may involve a mixture of in and out-of-network providers. However, surprise billing as defined in legislation does not occur at Engage Psychotherapy because you have direct control over who is involved in your care (i.e. your therapist) and psychotherapy session fees are discussed and agreed upon at outset.
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.
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 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.
Under existing legislation, Engage Psychotherapy is allowed to balance-bill since we are not contracted with any insurance plans. We charge you an agreed fee for our services and you are responsible for payment for either the full fee or, if your insurance company will pay us directly as an out-of-network provider, the portion of the session fee that insurance does not cover. However, if you are seeing a provider at a facility where balance billing isn’t allowed, you 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 NYS Dep of Financial Services.
Visit https://www.dfs.ny.gov/consumers/health_insurance/surprise_medical_bills for more information about your rights under federal law.