No Surprise Act
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Dear Valued Client,
All clinicians must comply with the No Surprises Act, which ensures that clients be made aware of the costs of healthcare. Please view the below information before your next appointment or before scheduling an appointment.
No Surprise Act
In Network
YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS
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(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.
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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.
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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,
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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.
When balance billing isn’t allowed, you also have the following protections:
You are only responsible for paying your share of the cost (copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay in-network providers and facilities directly.
Your health plan generally must:
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Cover emergency services without requiring you to get approval for services in advance (prior authorization).
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Cover emergency services by out-of-network providers.
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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.
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Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
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If you believe you’ve been wrongly billed, you may contact our office or primary insurance company to obtain clarity of billing.
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.
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THE NO SURPRISES ACT
STANDARD NOTICE AND CONSENT DOCUMENTS
(OMB Control Number: 0938-1401)
SURPRISE BILLING PROTECTION FORM
The purpose of this document is to let you know about your protections from unexpected medical bills. It also asks whether you would like to give up those protections and pay more for out-of-network care.
You’re getting this notice because this provider or facility isn’t in your health plan’s network. This means the provider or facility doesn’t have an agreement with your plan.
Getting care from this provider or facility could cost you more.
If your plan covers the item or service you’re getting, federal law protects you from higher bills:
When you get emergency care from out-of-network providers and facilities, or
when an out-of-network provider treats you at an in-network hospital or ambulatory surgical center without your knowledge or consent.
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Ask your health care provider or patient advocate if you need help knowing if these protections apply to you.
If you sign this form, you may pay more because:
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You are giving up your protections under the law.
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You may owe the full costs billed for items and services received.
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Your health plan might not count any of the amount you pay towards your deductible and out- of-pocket limit. Contact your health plan for more information.
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You shouldn’t sign this form if you didn’t have a choice of providers when receiving care. For example, if a doctor was assigned to you with no opportunity to make a change.
Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility. If there isn’t one, your health plan might work out an agreement with this provider or facility, or another one.
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Estimate of what you could pay
Out-of-network provider(s) or facility name: Lexington Magnuson, LMFT
​Total cost estimate of what you may be asked to pay: It is your ethical right to determine your goals for treatment and how long you would like to remain in therapy unless you are pursuing mandatory treatment. Please see the breakdown of possible fees on page five.
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Review your detailed estimate. See below for a cost estimate for each item or service.
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Call your health plan. Your plan may have better information about how much of these services are reimbursable.
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Questions about this notice and estimate? Please call to have your questions answered.
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Questions about your rights? Contact: Please contact your health plan to inquire about your health care rights.
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Prior authorization or other care management limitations
Except in an emergency, your health plan may require prior authorization (or other limitations) for certain items and services. This means you may need your plan’s approval that it will cover an item or service before you get them. If prior authorization is required, ask your health plan about what information is necessary to get coverage.]
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More information about your rights and protections
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.
By signing, I give up my federal consumer protections and agree I might pay more for out-of-network care.
With my signature, I am saying that I agree to get the items or services from:
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Selina Galvan, LMFT
With my signature, I acknowledge that I am consenting of my own free will and am not being coerced or pressured. I also understand that:
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I’m giving up some consumer billing protections under Federal law.
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I may get a bill for the full charges for these items and services or have to pay out-of-network cost-sharing under my health plan.
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I was given a written notice at my initial meeting explaining that my provider or facility isn’t in my health plan’s network, the estimated cost of services, and what I may owe if I agree to be treated by this provider or facility.
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I got the notice either on paper or electronically, consistent with my choice.
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I fully and completely understand that some or all amounts I pay might not count toward my health plan’s deductible or out-of-pocket limit.
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I can end this agreement by notifying the provider or facility in writing before getting services.
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IMPORTANT: You don’t have to sign this form. But if you don’t sign, this provider or facility might not treat you. You may take a picture and/or keep a copy of this form. It contains important information about your rights and protections.
​More details about your estimate
Out-of-network provider(s) or facility name: Selina Marie Galvan, LMFT
Provider NPI: 1639796311
The amount below is only an estimate; it isn’t an offer or contract for services. This estimate shows the full estimated costs of the items or services listed. It doesn’t include any information about what your health plan may cover. This means that the final cost of services may be different than this estimate.
​Contact your health plan to find out how much, if any, your plan will pay and how much you may have to pay.
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GOOD FAITH ESTIMATE: TABLE OF SERVICES AND FEES
​Service code (CPT Code): Description Fee for Service (Number of Sessions Will Be Determined as We Progress)
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90791 Initial Diagnostic Evaluation
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$150 (Some Sliding Scale Appointments are available)
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90837 Psychotherapy ≥ 53 Minutes
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$125 (Some Sliding Scale Appointments are available)
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90839 Psychotherapy for a Crisis (30-74 minutes)
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$150
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90847 Family Psychotherapy with Patient Present, 50 minutes
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$150 (Some Sliding Scale Appointments are available)
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Cancellation or No Show Fee (Your Therapist Requires a 24-Hour Cancellation Fee)
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You are Responsible for the $125(individual) or $150 (family) Late Cancellation or No Show Fee of the Missed Appointment
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Total Estimate:
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This Good Faith Estimate explains your therapist’s rate for each service provided. Your therapist will collaborate with you throughout your treatment to determine how many sessions and/or services you may need to receive the greatest benefit based on your diagnosis(es)/presenting clinical concerns.
Please note that Place of Service (in office vs. telehealth) is not delineated above since the charges are identical.
