Your Right to Receive a Good Faith Estimate of Expected Charges

(Under the No Surprises Act)

You have the right to receive a Good Faith Estimate explaining how much your health care services are expected to cost.

Under federal law, health care providers must give patients who do not have insurance or who choose not to use insurance an estimate of expected charges for medical items and services.

You have the right to receive a Good Faith Estimate for the total expected cost of non-emergency services, including any related services that are reasonably expected.

For most outpatient therapy services, this estimate typically reflects the session fee and does not include additional services such as medical tests, prescriptions, or hospital fees.

Your provider will give you a Good Faith Estimate in writing:

• At least 1 business day in advance for services scheduled 3–9 days out

• At least 3 business days in advance for services scheduled 10 or more days out

You may also request a Good Faith Estimate at any time before scheduling services.

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

Please save a copy of your Good Faith Estimate for your records.

For more information about your rights under the No Surprises Act, visit
www.cms.gov/nosurprises
or contact the Colorado Division of Insurance at (303) 894-7490 or 1-800-930-3745.

Your Rights and Protections Against Surprise Medical Bills

(OMB Control Number: 0938-1401)

Under federal law, when you receive certain health care services, you are protected from surprise billing and balance billing.

What is surprise billing or balance billing?
When you see a health care provider, you may owe cost-sharing (like copayments, coinsurance, and deductibles). If a provider or facility isn’t in your health plan’s network, they may bill you for the difference between your plan’s payment and their full charge. This extra amount is called balance billing. A surprise bill is a balance bill you didn’t expect.

When am I protected?
You are protected from surprise billing in these situations:

1. Emergency care
If you need emergency services, you can’t be balance billed by an out-of-network provider or facility. You only owe your in-network cost-sharing amount (like a copay or coinsurance).

2. Certain services at in-network facilities
If you get care at an in-network hospital or ambulatory surgical center, some providers there (such as anesthesiologists, radiologists, pathologists, or hospitalists) may be out-of-network. In these situations, you’re still only responsible for your in-network cost-sharing and cannot be balance billed.

You do not have to give up these protections in order to receive care.

Your health plan must:
• Cover emergency services without requiring prior authorization.
• Cover emergency services by out-of-network providers.
• Base your cost-sharing on in-network rates.
• Count your payments toward your deductible and out-of-pocket limit.

What if I think I was wrongly billed?
If you believe you received a surprise bill, you may contact:
• Cloudline Counseling PLLC (your provider)
• Colorado Division of Insurance at (303) 894-7490 or 1-800-930-3745

Note: These protections generally apply to emergency services or care received at hospitals or surgical centers. Most outpatient therapy services do not involve surprise billing.

For more information about your rights under federal law, visit:
https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf