Disclosure Notice Regarding Patient Protections Against Surprise Billing

Note to Clients

Effective January 1, 2022, a ruling went into effect called the "No Surprises Act," which requires mental health practitioners to provide a "Good Faith Estimate" (GFE) to patients who do not have insurance or patients who have insurance but are out-of-network. The Good Faith Estimate's purpose is to show the cost of services to avoid an unreasonably large bill. Clients will be provided forms called the “Surprise Billing Protection Form” and the “Good Faith Estimate,” which are provided to you if you are paying privately and are not using in-network insurance benefits. The federal bill requiring licensed healthcare providers to provide these forms was not created with input from or consultation with mental health professionals, and its intended use is to protect people from surprise medical bills, mostly in an inpatient hospital setting. Therapists already provide advance and clear notice of our fees, as our professional ethics have always required us to do. It is federal law that these be provided to clients and that this notice is included on my website.

Your treatment and cost of treatment will vary based on your individual needs, amount of therapy sessions needed/wanted, and the type and length of services you attend. I have no way of predicting the exact amount of therapy sessions or services that will be needed however, you will be provided some examples of total cost of treatment for reference. Please remember you can always discuss billing, cost, treatment plan, length of sessions, and amount of sessions with me at any time.

This ruling requires me to diagnosis you before our initial visit (which I believe is unethical) so, I provide you with a generic diagnosis Z71.9 for Counseling, unspecified. If you wish to have a formal diagnosis, we can discuss. Note that many clients do not wish to have a diagnosis and desire to focus treatment on symptoms and areas of growth instead. This is totally your preference, and I am open to talking about both with you.

No document clients sign, including the ones related to No Suprise Billing, is a contract and does not obligate you to obtain any services from Emily St. Amant Counseling, PLLC. The Good Faith Estimate is not intended to serve as a recommendation for treatment or prediction to attend a specific number of psychotherapy visits nor does it provide an all-inclusive treatment plan. Therapy is and will always be voluntary and unique to fit your specific needs. See below for the language provided by CMS for more information about the bill and your rights.

Model Disclosure Notice Regarding Patient Protections Against Surprise Billing Instructions for Providers and Facilities (For use beginning January 1, 2022)

Section 2799B-3 of the Public Health Service Act (PHS Act) requires health care providers and facilities to make publicly available, post on a public website of the provider or facility (if applicable), and provide a one-page notice that includes information in clear and understandable language on:

(1) the restrictions on providers and facilities regarding balance billing in certain circumstances,

(2) any applicable state law protections against balance billing, and

(3) information on contacting appropriate state and federal agencies in the case that an individual believes that a provider or facility has violated the restrictions against balance billing.

Health care providers and facilities may, but aren’t required to, use this model notice to meet these disclosure requirements. To use this document properly, the provider or facility should review and complete it in a manner consistent with applicable state and federal law. HHS considers use of this model notice in accordance with these instructions to be good faith compliance with the disclosure requirements of section 2799B-3 of the PHS Act and 45 CFR 149.430, if all other applicable PHS Act requirements are met.

If a state develops model language for its disclosure notice that is consistent with section 2799B3 of the PHS Act, HHS will consider a provider or facility that makes good faith use of the statedeveloped model language to be compliant with the federal requirement to include information about state law protections.

Public Disclosure Requirements

The disclosure notice must be publicly available, and (if applicable) posted on a provider’s or facility’s public website.

—To satisfy the public disclosure requirement, providers and facilities must prominently display a sign with the required disclosure information in a location of the provider or facility, such as, where individuals schedule care, check-in for appointments, or pay bills, unless the provider doesn’t have a publicly accessible location.

-To satisfy the separate requirement to post the disclosure on a public website, the disclosure or a link to the disclosure must appear on a searchable homepage of the provider’s or facility’s public website.

The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.

Who should get this notice

In general, providers and facilities must give the disclosure notice to individuals who are participants, beneficiaries, or enrollees of a group health plan or group or individual health insurance coverage offered by a health insurance issuer, including covered individuals in a health benefits plan under the Federal Employees Health Benefits Program, and to whom they furnish items or services, and then only if such items or services are furnished at a health care facility, or in connection with a visit at a health care facility.

Provision of the notice

Providers and facilities must provide the notice in-person, by mail, or via email, as selected by the individual. The disclosure notice must be limited to one-page (double-sided) and must use a font size of 12-points or larger.

Providers and facilities must issue the disclosure notice no later than the date and time on which they request payment from the individual (including requests for copayment or coinsurance made at the time of a visit to the provider or facility). If the provider or facility doesn’t request payment from the individual, the notice must be provided no later than the date on which the provider or facility submits a claim for payment to the plan or issuer.

Language access

Use of Plain Language

Health care providers, facilities, plans, and issuers are encouraged to use plain language in the disclosure notice and test the notice for clarity and usability when possible.

Plain language, accessibility, and language access resources:

- Plainlanguage.gov/guidelines

- Section508.gov

-LEP.gov

Compliance with Federal Civil Rights Laws

Entities that receive federal financial assistance must comply with federal civil rights laws that prohibit discrimination. These laws include section 1557 of the Affordable Care Act, Title VI of the Civil Rights Act of 1964, and section 504 of the Rehabilitation Act of 1973.

Section 1557 and title VI require covered entities to take reasonable steps to ensure meaningful access to individuals with limited English proficiency, which may include offering language assistance services such as translation of written content into languages other than English. Section 1557 and section 504 require covered entities to take appropriate steps to ensure effective communication with individuals with disabilities, including provision of appropriate auxiliary aids and services. Auxiliary aids and services may include interpreters, large print materials, accessible information and communication technology, open and closed captioning, and other aids or services for persons who are blind or have low vision, or who are deaf or hard of hearing. Information provided through information and communication technology also must be accessible to individuals with disabilities, unless certain exceptions apply. Providers and facilities are reminded that the disclosure notice must comply with applicable state or federal language-access standards.

NOTE: The information provided in these instructions is intended to be only a general summary of technical legal standards. It is not intended to take the place of the statutes, regulations, or formal policy guidance on which it is based. Refer to the applicable statutes, regulations, and other interpretive materials for complete and current information.