No Surprises Act 2022

Professional Counseling Care Associates, LLC

487 Carlisle Drive, Herndon, VA 20170703-328-4937 | Professionalcounselingcarelpc@gmail.com www.annemckaycounseling.com

Standard Notice: Your Right to Receive a Good Faith Estimate of Expected Charges

Under the No Surprises Act

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

Key Points to Know:

Healthcare providers are required by law to give patients who are uninsured or not using insurance a Good Faith Estimate for medical services.
This estimate will include the total expected cost of any non-emergency services, including related costs like tests, prescription drugs, equipment, and hospital fees.

What You Should Do:

Ensure your provider gives you a Good Faith Estimate in writing at least one business day before your scheduled service or item.
You can also request a Good Faith Estimate before scheduling a service.
Keep a copy of your Good Faith Estimate for your records.

If You Receive a Bill Exceeding Your Estimate:If you receive a bill that is $400 or more than your Good Faith Estimate, you have the right to dispute the charges.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call [Insert Practitioner’s Phone Number].

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?

Balance billing occurs when you receive a bill for the difference between what your health plan agrees to pay and what the provider charges for a service.

Out-of-Network Providers: Providers or facilities not contracted with your health plan may balance bill you for additional costs.
Surprise Billing: This unexpected bill may occur when you cannot control who is involved in your care, such as in emergencies or when an in-network facility uses an out-of-network provider.

Protections from Balance Billing

You are protected from balance billing for the following situations:

Emergency Services:

If you receive emergency services from an out-of-network provider or facility, the most you can be charged is your in-network cost-sharing amount (e.g., copayments or coinsurance).
This protection applies even after you are stabilized unless you give written consent to waive your rights and agree to balance billing.

Certain Services at In-Network Hospitals or Ambulatory Surgical Centers:

When receiving services at an in-network facility, some providers (e.g., anesthesiologists, radiologists, pathologists) may be out-of-network. These providers cannot balance bill you and cannot require you to waive your rights unless you give written consent.

Your Choices and Protections:

You are not required to waive your protections from balance billing.
You always have the option to choose in-network providers or facilities.

For more information about your rights and protections, visit www.cms.gov/nosurprises.