(OMB Control Number: 0938-1401)
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.
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.
“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.
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.
The state of Georgia and the federal government both have laws to protect you from balance billing although they are a little different. State rules only apply to fully insured commercial health insurance plans and some government plans. Federal rules may also apply to commercial health insurance in situations where you received health care services in another state, your health insurance is regulated by a state other than Georgia or the health care service you received is not regulated by the state law. Most of the differences between the state and federal laws are in the way the rules affect providers and health insurers, so you usually won’t need to worry about that. However, the grievance processes are different, as indicated on the government websites linked below.
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 your consent. 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.
Uninsured or Self-Pay patients
Some provisions of the No Surprises Act are inapplicable to patients who are uninsured or who are self-pay. Instead, uninsured/self-pay patients are generally entitled to a “good faith estimate” for non-emergency services.
Georgia State Protections
Many of the same protections afforded by the federal law are mirrored in the Georgia state law, but there are some key differences. The Georgia law only applies to self-insured employer health plans and government plans and is limited to services provided in Georgia. In addition to hospitals and ambulatory surgery centers, the Georgia law also applies to certain imaging centers, birthing centers, and similar facilities. Further, Georgia law has a different grievance process and disclosure requirements than the federal law. Definitions under the Georgia law and the federal law, although similar, may not be identical.
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:
Visit this page to download a PDF for more information about your rights under Federal law. You can also visit the Office of Commissioner of Insurance and Safety Fire for more information.
Under the Georgia Surprise Billing Consumer Protection Act (a Georgia state law) and the No Surprises Act (a federal law), there may be certain circumstances where therapists and/or contractors involved with Insight Out Therapeutics provide you a notice and consent document (e.g. surgical services, cancer services, long term care services, transplants). This notice and consent document will describe certain non-emergency items or services to be provided by healthcare providers who are out-of-network with your insurance/health plan and will seek your consent to receive that care and permit those providers to bill at out-of-network rates.
Neither Insight Out Therapeutics, nor Charles Lenahan, nor any contractors with Insight Out Therapeutics developed the notice and consent document. The notice and consent document is a standard form created by the United States Department of Health and Human Services which healthcare providers are required to use with only minimal modification.
If you are requested to complete a notice and consent document, you are not required to provide your consent. However, the providers are not required to provide the care in the absence of the consent. If you do not provide consent, you may instead choose to seek care from a different provider who may be in-network with your insurer/health plan. We encourage you to reach out to your insurer/health plan to find providers who are in-network.
Insight Out Therapeutics does not have information regarding all providers that may be in-network with your insurance/health plan. Insight Out Therapeutics will always seek to honor a client's choice of provider to the greatest extent possible.
This document was originally written by the Centers for Medicaid and Medicare (December 2021) and posted on their website (see reference below). The No Surprises Law has already seen several revisions, so it is subject to change. This document on the CMS website actually has an expiration date of 3/31/22. It is each therapist’s duty to make certain they stay in compliance with any updates. Please note that Charles Lenahan is not an attorney, nor does he or Insight Out Therapeutics or its staff or contractors guarantee this document in any way. It is merely one option to consider based on the information discussed in the Webinar that accompanies this document.
Centers for Medicare and Medicaid Services (2021). Standard Notice and Consent Documents under the No Surprises Act (For use by nonparticipating providers and nonparticipating emergency facilities beginning January 1, 2022).
Pursuant to the No Surprises Act, clients who are uninsured or self-pay are generally entitled to a good faith estimate of costs and services for non-emergency care in most circumstances. We will update this as time progresses and we are notified of changes made to the law at federal and state levels.
Hospitals and ambulatory surgical centers are required to provide patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services based on information known at the time. This estimate will assist in explaining how much your medical care is anticipated to cost. As Insight Out Therapeutics is not an emergency medical facility, this generally does not apply to this practice nor to the therapists contracted with the company.
Please note that a good faith estimate is an estimate based on information known at the time with respect to anticipated non-emergency items/services. The good faith estimate is not a guarantee that your final costs will match the estimate. This means that the final cost of services may be different than this estimate. Final costs for which you are billed may vary for many reasons. This may be due to a client's condition, unknown circumstances or complications, and recommended treatment ordered by the healthcare provider.
You have the right to receive a good faith estimate for the total expected cost of non-emergency items or services at any healthcare facility. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees. You can request a good faith estimate from any therapist at Insight Out Therapeutics at any time.
For more information, we encourage you to visit this webpage regularly to check for additional information and updates. Different time frames apply with respect to providing you a good faith estimate depending on when or how far in advance your care is scheduled. We at Insight Out Therapeutics endeavor to provide all estimates as soon as practicable.
If you believe you have not been provided a good faith estimate when you were supposed to receive one, please let us know immediately. For more information, you can contact the United States Department of Health and Human Services regarding the federal law. You may also visit the Georgia Office of the Commissioner of Insurance and Fire Safety website or call them at 404-656-2070 with any questions regarding the Georgia law.