No Surprises Disclosure

Protections Against Surprise Medical Bills

Outpatient Services

When you see a doctor or other healthcare provider at an outpatient location (such as an office or via telehealth), there are two common billing scenarios:

  • If the provider is in-network with your insurance plan, you may owe certain out-of-pocket costs like a copay or deductible.

  • If the provider is out-of-network, you may have additional costs or have to pay the entire bill.

Out-of-network means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays 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 plan’s deductible or annual out-of-pocket limit.

Emergency & Ambulatory Services and Hospitals

“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. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

You’re 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 they can bill you is your plan’s in-network cost-sharing amount (such as copay and deductibles). 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 can 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 types of services at these in-network facilities, such as follow-up appointments, 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 out-of-network care. You can choose a provider or facility in your plan’s network.

When balance billing isn’t allowed, you also have these protections:

  • You’re only responsible for paying your share of the cost (like the copay and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.

  • You health plan should cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).

  • You plan should cover emergency services by out-of-network providers.

  • Your health insurance should base what you owe the provider or facility (cost-share) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.

  • Your plan should count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

If you think you’ve been wrongly billed, contact Arizona Secretary of State, Katie Hobbs. The website is https://azsos.gov. The main number is 602-542-4285.

Good Faith Estimates

Under the law, healthcare 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. This is called a “Good Faith Estimate.”

Here’s what you should know about Good Faith Estimates:

  • 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.

  • You can also ask your healthcare 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.

Good Faith Estimates & Therapy

Private practice psychotherapy is different from other types of healthcare in that services are provided on a session-by-session basis. This means that you may choose to continue or end all services at any point in the year and it is entirely up to you, not your therapist. You will never be charged more than the fee for the service that you agree to by choosing to schedule and continue your course of treatment.

The total amount you may pay will be the fee for the session X the number of sessions. This depends on the length of treatment which cannot be predicted.

In the case of this practice, session fees are standard regardless of diagnosis or whether it takes place face-to-face in the office or virtually via telehealth.

 Visit  https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf or call 888-551-5168 for more information about your right to a Good Faith Estimate.