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No Surprise Act

YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS

(OMB Control Number: 0938-1401) (Updated 12.17.2024)

This notice is a requirement of the “No Surprises Act” and the content below may not seem to apply to the services provided to you at Integrative Trauma Treatment Center (ITTC); however, we are providing this notification as required by law.

When you get emergency care or are treated by an out-of-network provider at an in-network facility, you are protected from surprise billing or balance

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 healthcare facility that is not in your health plan’s network.

“Out-of-network” refers to providers and facilities that do not have a contract with your health plan. Out-of-network providers may bill you for the difference between what your plan pays and the full cost of a service. This is called “balance billing.” The amount billed is typically higher than in-network costs and may not count toward your annual out-of-pocket limit.

“Surprise billing” happens when you receive an unexpected balance bill. This can occur if you have no control over who is providing your care—such as during an emergency or when you receive treatment at an in-network facility but are unknowingly treated by an out-of-network provider.

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 you can be billed is your plan’s in-network cost-sharing amount (e.g., copayments or coinsurance). You cannot be balance billed for these emergency services. This includes services provided after you are stable unless you give written consent to waive these protections.

Certain services at an in-network hospital or ambulatory surgical center

When you receive care at an in-network hospital or ambulatory surgical center, some providers there may not be in-network. In these cases, the most they can bill you is your in-network cost-sharing amount. This applies to services like:

  • Emergency medicine
  • Anesthesia
  • Pathology
  • Radiology
  • Laboratory
  • Neonatology
  • Assistant surgery
  • Hospitalist services
  • Intensivist services

Out-of-network providers cannot balance bill you for these services and cannot ask you to waive these protections.

If you receive other services at an in-network facility, out-of-network providers can balance bill you only if you give written consent to waive 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 costs (e.g., copayments, coinsurance, deductibles) for in-network services.
  • Your health plan will pay out-of-network providers directly.
  • Your health plan must:
    • Cover emergency services without prior authorization.
    • Cover emergency services provided by out-of-network providers.
    • Base your cost-sharing on the in-network rate.
    • Count your payments for emergency or out-of-network services toward your deductible and out-of-pocket maximum. 

If you believe you’ve been wrongly billed, you may contact:

OBOP 3218 Pringle Road SE, Ste. 130 Salem, OR 97302 503-378-4154 psychology.board@oregon.gov
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.