No Surprises Act

Sandra G. Carey, PsyD and the Center for Vitality and Balance is a provider for BlueCross/BlueShield PPO, BlueCross/Blue Choice PPO and Medicare. Insurance claims will automatically be submitted electronically. This service is included in the session fee.

If you do not have BlueCross BlueShield PPO or BlueCross Blue Choice PPO, then you are out-of-network with the Center. The Illinois No Surprises Act requires us to give you a statement identifying our fees and what you will be responsible for. Your out-of-network insurance may or may not pay a portion of our fees. We encourage you to find out if you have out-of-network benefits with your insurance company and what the deductible is for out-of-network providers.

If you pay out-of-pocket or decide not to use your insurance or have out-of-network insurance, your psychotherapist will provide you with a statement explaining the fees. See more information below about your rights and protections against surprise medical bills and the “No Surprises Act.”

FEES

• Initial Evaluation: $200.00 (55 minutes)

• Individual Session: $150.00 (38-52 minutes)

• Individual Session: $180.00 (55 minutes)

• Cancellation Fee: $100 for missed appointment, without 24-hour notice of cancellation

• Production of Records: $25.00 per hour

• Legal Fees: $200.00 per hour plus reimbursement of fees paid by the therapist for legal consultation about the case.

YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS “NO SURPRISES ACT”

When you see a 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 if you see a provider out-of-network with your insurance policy

Surprise billing is an unexpected bill for provided services. This can happen in cases of emergency care or when you receive services by an out-of-network provider.

HOW THE NO SURPRISES ACT PERTAINS TO CLIENTS AT THE CENTER FOR VITALITY AND BALANCE

At the Center for Vitality and Balance, Dr. Sandra Carey is in-network with three providers: BlueCross BlueShield PPO and BlueCross BlueChoice PPO and Medicare. If you are in one of these two plans then you will follow your plan and pay the deductible amount each new year, usually starting January 1, as well as the co-pays or co-insurances that your insurance company requires.

Except in an emergency, your health plan may require prior authorization (or other limitations) for certain items and services. If prior authorization is required, ask your health plan about what information is necessary to get approval for coverage.

If you do not have BlueCross BlueShield PPO or BlueCross BlueChoice PPO, then you are out-of-network with our Center. The Illinois No Surprises Act requires us to give you a statement identifying our fees and what you will be responsible for. Your out-of-network insurance may or may not pay a portion of our fees. We encourage you to find out if you have out-of-network benefits with your insurance company and what the deductible is for out-of-network providers.

If you pay out-of-pocket or decide not to use your insurance or have out-of-network insurance, your psychotherapist will provide you with a statement explaining the fees.

Exceptions to Illinois Surprise Billing Protections

You could still be required to pay an out-of-network bill in certain situations. Illinois’ surprise billing protections only apply to insurance plans regulated by the state of Illinois. Therefore, if your insurance plan is not regulated by the state, you may still be billed for these out-of-network charges. Further, these protections only apply to certain out-of-network providers who are based in an in-network facility; if the facility where you receive these services itself is out-of-network, you can also receive an out-of-network bill. Similarly, these protections do not apply if you purposely choose a provider not within your insurance network.

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

The Illinois Department of Insurance
320 West Washington Street Springfield, IL 62767
1-877-527-9431

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.

(OMB Control Number: 0938-1401)