No Surprise Billing

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or are treated by an out-of-network provider, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

What is “balance billing” (sometimes called “surprise billing”)?  

When you see a Wellness Matters LLC therapist, you may owe certain out-of-pocket costs. For example, you may have a copayment, coinsurance, or deductible to meet, depending on your insurance plan. You may have additional 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” means Wellness Matters LLC and/or its providers haven’t 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’re protected from balance billing for: 

Emergency services 

If you 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 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.

Note: Wellness Matters LLC does not provide emergency services. If you experience an emergency, please go to your nearest hospital’s ER department.

When balance billing isn’t allowed, you also have protections:

You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.

Generally, your health plan must:

  • Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
  • Cover emergency services by out-of-network providers.
  • 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.
  • Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

If you think you’ve been wrongly billed, please contact Rita Anderson, Owner of Wellness Matters LLC at 218-255-3321 or visit the CMS website at https://www.cms.gov/nosurprises/consumers for more information about your rights under federal law.