Good Faith Policy and No Surprises Act

Your Rights and Protections Against Surprise Medical Bills

When you receive emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, federal law protects you from surprise billing, also called balance billing.

What Is Balance Billing (or Surprise Billing)?

• Balance billing happens when an out-of-network provider bills you for the difference between what your insurance pays and the total charge.
• Out-of-network refers to providers and facilities that do not have a contract with your insurance plan. Costs from out-of-network providers may exceed in-network rates and may not count toward your annual out-of-pocket limit.
• Surprise billing is an unexpected balance bill. This may occur in emergencies or when you receive care from an out-of-network provider at an in-network facility without your knowledge.

You Are Protected from Balance Billing For:

• Emergency services: If you have an emergency medical condition and receive care from an out-of-network provider or facility, the most you can be billed is your in-network cost-sharing amount (copayments, coinsurance). You cannot be balance billed for these services. Post-stabilization services require written consent to waive these protections.
• Certain services at in-network hospitals or surgical centers: Out-of-network providers performing services such as emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist cannot balance bill you and may not require you to give up your protections.

For other services at in-network facilities, out-of-network providers may balance-bill you only with your written consent.

You are never required to waive your protections from balance billing and may always choose in-network providers.

Additional Protections

• You are only responsible for your in-network share of costs.
• Your health plan generally covers emergency services without prior authorization.
• Emergency and out-of-network payments count toward your deductible and out-of-pocket maximum.

If you believe you have been wrongly billed, call 1-800-985-3059 or visit www.cms.gov/nosurprises/consumers.

Your Right to a Good Faith Estimate

• Patients without insurance, or those not using insurance, have the right to a Good Faith Estimate for the expected cost of medical items or services.
• This estimate must include related costs such as tests, prescriptions, equipment, and hospital fees.
• You will receive your estimate in writing at least 1 business day before your service. You can also request an estimate before scheduling.
• If you are billed $400 or more above your estimate, you may dispute the charge.
• Keep a copy or photo of your Good Faith Estimate.

For more information, visit www.cms.gov/nosurprises or call 1-800-985-3059.

Patient Notice of Financial Assistance

Our practice is committed to quality care and helping patients manage costs:

• Payment at time of service: Insurance copays or self-pay amounts are collected at discharge or check-in.
• Eligibility & Enrollment Services (EES): Free assistance with government programs or Health Exchange coverage.
• Charity Care Program: For patients with household income below 400% of the federal poverty level and high medical expenses.
• Uninsured Discount Program: Discounts comparable to commercial insurance rates.
• Other programs: Medicaid/Medi-Cal, Temporary Assistance for Needy Families, Social Security Disability, Supplemental Security Income, County Indigent programs, and more.

This notice and the Good Faith Estimate are available in other languages upon request.

For questions, language assistance, or to apply for financial assistance, contact EES at 800-374-4637.