Insurance and Fees

Good Faith Estimate & No Surprises Act

Out of Pocket and Out of Network Right to Good Faith Estimate Notice

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STANDARD NOTICE

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“Right to Receive a Good Faith Estimate of Expected Charges”

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Under the No Surprises Act

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You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

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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.

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-You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

-Make sure your health care provider gives you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your health care provider, and any other provider you choose for a Good Faith Estimate before you schedule an item or service.

-If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

-Make sure to save a copy or picture of your Good Faith Estimate.

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For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or contact Meredith Stockton at info@infostocktonwellness.com.

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No Surprises Act Notice

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YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE

MEDICAL BILLS

(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.

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.

“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-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 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.

Surprise Billing in Illinois

Illinois state law (Illinois Public Act 096-1523) protects you from “balance” or “surprise” bills when you receive care at an in-network facility or ambulatory surgery center from out-of-network providers who provide radiology, anesthesiology, pathology, neonatology, or emergency physician services at that in-network facility.

In these situations, you cannot be charged greater out-of-pocket expenses than you would have been for covered, in-network physician or provider services. The out-of-network provider should not send you a bill.

Exceptions to Illinois Surprise Billing Protections

You could, however, still be required to pay an out-of-network bill in certain situations. Illinois’ surprise billing protections only apply to insurance plans regulated by the state of Illinois. Therefore, if your insurance plan is not regulated by the state, you may still be billed for these out-of-network charges. Further, these protections only apply to certain out-of-network providers who are based in an in-network facility; if the facility where you receive these services itself is out-of-network, you can also receive an out-of-network bill. Similarly, these protections do not apply if you purposely choose a provider not within your insurance 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 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 Illinois Department of Insurance
320 West Washington Street Springfield, IL 62767
1-877-527-9431

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.