Insurance

Evergreen Counseling is an out-of-network provider which means that we do not bill insurance companies directly.

However, your counseling services may be eligible for reimbursement through your insurance plan’s out-of-network mental health benefits, medical spending, or health care savings accounts.

Because health insurance plans and benefits vary, we recommend you give your health insurance customer service number a call and inquire about your out-of-network mental health benefits to understand what percentage you may be reimbursed if you work with us.

Evergreen Counseling will then provide you with a superbill (an itemized medical receipt) at the end of each month which you can submit to your insurance company for out-of-network coverage/reimbursement directly back to you. However, please note that you will be responsible for payment at the time of service.

Evergreen Counseling accepts credit cards, debit cards, and HSA cards. We do not accept checks or cash.

Evergreen Counseling A Marriage and Family Therapy Corporation

| DBA: Evergreen Counseling | 2140 Shattuck Avenue, #804, Berkeley, CA, 94704 | phone: 510-373-2723 | fax: 510-993-0373 | www.EvergreenCounseling.com

YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS

(OMB Control Number: 0938-1401)

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

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 health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care – like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

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

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can’t balance bill you unless you give written consent and give up 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 cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
• Your health plan generally must:
  • Cover emergency services without requiring you to get approval for services in advance (prior authorization).
  • Cover emergency services by out-of-network providers.
  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
  • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

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

• The U.S. Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (1-800-633-4227) or visit https://www.cms.gov/nosurprises for more information about your rights under federal law.
• If you believe you’ve been wrongly billed, contact the California Department of Insurance and Financial Institutions at (800) 967-9331
• Visit for Provider Independent Dispute Resolution Process for more information about your rights under California law.

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.

Good Faith Estimate Notice

You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services.

You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.

Why don’t we take insurance?

Here at Evergreen Counseling, we choose to work outside of insurance companies for a variety of reasons:

1) We want our clients to be able to determine the length, frequency, and type of therapy they receive. When you use your insurance plan to obtain therapy, the insurance companies can often dictate how long you can be in therapy or even what kind of therapy you can receive.

2) Client privacy and protection. When using insurance to pay for therapy, a mental health diagnosis is required which then goes onto your permanent medical record, possibly creating an impact when applying for life and medical insurance coverage, or possibly limiting future employment opportunities. At Evergreen Counseling, we like to empower our clients to choose whether or not they want to have a diagnosis on their medical record. By being out-of-network and private pay, we can allow our clients the highest degree of privacy, flexibility, and control of their medical records allowed by California state law.