No Surprises Act

Effective Jan. 1, 2022, health care providers, including mental health care providers, and facilities must comply with consumer protections and disclosure processes, specific to health care service fees, in an effort to reduce surprise medical billing. Among its provisions, the legislation limits the amount that providers can charge for out-of-network costs. Counselors working in emergency mental health care settings will be most impacted by this requirement, as they are more likely to provide care to an out-of-network patient. In-depth information is provided on the Centers for Medicare & Medicaid Services (CMS) website, and an easy-to-understand overview of the impact of this legislation on providers is available for download in PDF format.

A key provision of the legislation for most counselors is the “good faith estimate” requirement. This mandate requires that health care providers, including counselors, provide uninsured or self-pay clients/patients with an estimate of expected charges before services are provided. This estimate must be provided before the provision of services to both new and existing clients and must include anticipated charges for the service being provided and for any other items or services that are projected to be part of the same scheduled care experience or service. At present, providers are only responsible for providing good faith estimates for the services or items they will provide to the client, but in 2023, providers will be required to provide good faith estimates for co-provider or co-facility costs that are expected to be incurred by clients as part of their service.

Parameters of the good faith estimate requirement, as noted on the CMS site, include that providers and facilities must:

Provide a good faith estimate to an uninsured (or self-pay) individual: Within 1 business day after scheduling (this timeline applies when the primary item or service is scheduled at least 3 business days before the day the client or patient would receive it) or no later than 3 business days after scheduling (this timeline applies when the primary item or service is scheduled at least 10 business days before the client or patient would receive it), depending on scheduling; or Within 3 business days after an uninsured (or self-pay) consumer requests a good faith estimate. Include in the good faith estimate an itemized list of each item or service, grouped by each provider or facility offering care. Each item or service must share specific details and the expected charge. Provide a paper or electronic copy of the good faith estimate, even if the provider also provides the good faith estimate information to the individual over the phone or verbally in-person. Provide the good faith estimate using clear and understandable language. CMS has also provided instructions and an example/template providers can use to create a good faith estimate.

If service costs exceed the initially provided estimate by $400 or more, clients may dispute the charge. The process for disputing these charges is outlined in detail on the CMS site.

These key protections will help to ensure that clients/patients are not subject to extra, unexpected bills for health services. Though the process will initially require additional work to prepare the good faith estimate by counselors, hopefully, in the long run, we’ll find that the system reinforces and supports key principles of good relationships between care providers and clients. For more information, visit the CMS No Surprises Act site at cms.gov/nosurprises.