No Surprises Act

Your Rights and Protections Against Surprise Medical Bills

Effective January 1, 2022, the No Surprises Act protects you from unexpected medical bills. This notice explains your rights under federal law.

Your Rights Under Federal Law

When you receive care from Blue Rock Therapy, LLC, you are protected from certain surprise bills or balance bills. In these cases, you should not be charged more than your plan's copayments, coinsurance, and/or deductible.

What is Balance Billing?

When you see a healthcare provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a healthcare facility that is not in your health plan's network.

"Out-of-network" means providers and facilities that have not 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.

You Are Protected From Balance Billing For:

Emergency Services

If you have an emergency medical condition and receive 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 copayments, coinsurance, and deductibles). You cannot be balance billed for these emergency services. This includes services you may receive after you are stabilized, 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 Healthcare Facility

When you receive services from an in-network healthcare facility, certain providers at that facility 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 cannot balance bill you and may not ask you to give up your protections not to be balanced billed.

Good Faith Estimate

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including therapy and counseling services.

When You Can Request a Good Faith Estimate:

  • You are uninsured (self-pay)

  • You are insured but choose not to use your insurance

  • Your insurance does not cover mental health services

  • You are seeking services from an out-of-network provider

What Your Good Faith Estimate Will Include:

  • Expected charges for therapy sessions

  • Frequency and duration of recommended treatment

  • Any additional fees or costs

  • Provider contact information

You can request a Good Faith Estimate at the time of scheduling or anytime before your first appointment. You should receive this estimate within 3 business days (for advance scheduling) or at the time of scheduling (for same-day appointments).

If You Are Billed More Than Your Good Faith Estimate

Under the law, healthcare providers need to give patients who are not using insurance an estimate of their bill for medical services before those services are provided.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

Your Options If Billed More:

  • Ask your provider to update the bill to match the Good Faith Estimate

  • Negotiate the bill with your provider

  • Explore financial assistance options

  • Start a dispute resolution process with the federal government

Patient-Provider Dispute Resolution Process:

You have the right to initiate a patient-provider dispute resolution process if you receive a bill that is at least $400 more than your Good Faith Estimate. To start this process:

  • You must initiate the dispute within 120 calendar days of the date on the bill

  • There is a $25 administrative fee to initiate the dispute process

  • An independent dispute resolution entity will review your case

  • If the dispute is decided in your favor, you will only pay the amount in the Good Faith Estimate

  • If decided in the provider's favor, you must pay the full billed amount

How to Start a Dispute or Get More Information

To learn more about your rights under federal law or to initiate a dispute resolution process:

Federal Resources: