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Towler Counseling LLC Policies

YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS

(OMB Control Number: 0938-1401)

When you receive emergency care or are 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” (also known as “surprise billing”)?

When you visit a doctor or healthcare provider, you may owe certain out-of-pocket costs, such as copayments, coinsurance, or a deductible. If you see a provider or visit a healthcare facility that is not in your health plan’s network, you could be responsible for additional costs or the entire bill. Please note that there may be a late cancellation fee of up to $175.

Out-of-network refers to providers and facilities that do not have a contract with your health plan. Out-of-network providers may bill you for the difference between what your plan agrees to pay and the full amount charged for a service; this is referred to as "balance billing." This amount is typically higher than the in-network costs for the same service and may not count toward your annual out-of-pocket limit.

Surprise billing occurs when you receive an unexpected balance bill, often in situations where you cannot control who is involved in your care. This can happen during an emergency or when you visit an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

1. Emergency Services

If you are experiencing an emergency medical condition and receive services from an out-of-network provider or facility, the maximum amount the provider can bill you is your plan’s in-network cost-sharing amount (like copayments and coinsurance). You cannot be balance billed for these emergency services. This protection also applies to services received after your condition has stabilized unless you provide written consent to waive your protections regarding post-stabilization services.

2. Certain Services at an In-Network Hospital or Ambulatory Surgical Center

If you receive services from an in-network hospital or ambulatory surgical center, some providers may still be out-of-network. In such cases, the most those providers can bill you is your plan's in-network cost-sharing amount. This applies to services such as emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers cannot balance bill you and may not require you to waive your protections against balance billing.

If you receive other services at an in-network facility, out-of-network providers cannot balance bill you unless you give written consent and waive your protections.

You are never obligated to waive your protection against balance billing, nor are you required to receive care from out-of-network providers. You have the right to choose a provider or facility that is in your plan’s network.

When balance billing is not allowed, you also have the following protections:

You are responsible only for your share of the cost (such as copayments, coinsurance, and deductibles as if the provider or facility were in-network).
Your health plan will pay out-of-network providers and facilities directly.
Late cancellation fees may apply.

Your health plan generally must:

Cover emergency services without requiring prior authorization.
Cover emergency services provided by out-of-network providers.
Base your cost-sharing on the amount that would be paid to an in-network provider or facility and include this in your explanation of benefits.
Count any amounts you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you have been incorrectly billed, you may contact the Secretary of State for assistance.

For more information about your rights under federal law, please visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf.

TARA TOWLER-CUMBY