Effective Date: October 1, 2026

 

Federal and California laws provide protections against certain unexpected medical bills, sometimes called “surprise bills.” These protections generally apply when you receive emergency services from an out-of-network provider or facility or receive certain non-emergency services from an out-of-network provider at an in-network hospital, hospital outpatient department, or ambulatory surgical center.

 

Mensana Collaborative is a fee-for-service outpatient psychiatry and psychotherapy practice and does not participate as an in-network provider with health insurance plans. The federal surprise-billing protections described below do not generally apply merely because you knowingly choose to receive services from an out-of-network provider at a freestanding outpatient office such as Mensana Collaborative. Other federal or California protections may apply depending on the circumstances.

 

WHAT IS BALANCE BILLING?

When you receive health care from a provider or facility that is not in your health plan's network, the provider may sometimes bill you for the difference between what your health plan pays and the amount the provider charges. This is called “balance billing.”

 

A “surprise bill” is an unexpected balance bill. This may occur when you cannot control who is involved in your care, such as when you receive emergency services or when you receive care at an in-network facility but an out-of-network provider participates in your treatment without your expecting it.

 

WHEN YOU ARE PROTECTED FROM BALANCE BILLING

Emergency Services

If you have an emergency medical condition and receive emergency services from an out-of-network provider or facility, federal law generally limits the amount the provider or facility may bill you to your health plan's in-network cost-sharing amount, such as applicable copayments, coinsurance, and deductibles.

 

You generally cannot be balance billed for these emergency services. These protections also apply to certain post-stabilization services unless applicable legal requirements allowing otherwise have been satisfied.

 

Certain Services at an In-Network Facility

When you receive non-emergency services at certain in-network facilities, including hospitals, hospital outpatient departments, and ambulatory surgical centers, some of the individual providers involved in your care may be out-of-network.

 

In these circumstances, federal law generally protects you from balance billing by out-of-network providers for certain services. Your cost-sharing generally cannot exceed what you would have paid for the covered services if the provider had been in-network.

 

Certain ancillary services are subject to additional protections and generally cannot be balance billed. These can include services provided by anesthesiologists, pathologists, radiologists, neonatologists, assistant surgeons, hospitalists, and intensivists.

 

YOU ARE GENERALLY PROTECTED FROM HAVING TO GIVE UP THESE RIGHTS

In certain limited circumstances, an out-of-network provider may ask you to provide written consent to receive out-of-network care and waive certain balance-billing protections.

 

When federal law permits such consent, special notice, timing, language-access, and consent requirements apply. The notice and consent must be provided separately from other medical consent forms.

 

You are never required to give up your federal protections from balance billing simply because a provider asks you to do so. Some types of services cannot be subject to a waiver of these protections.

 

This Notice is not a request for you to waive any federal or California balance-billing protection.

 

WHEN THESE FEDERAL PROTECTIONS GENERALLY DO NOT APPLY

The federal protections described above are directed primarily at emergency services and certain services received in connection with an in-network hospital, hospital outpatient department, or ambulatory surgical center.

 

They generally do not apply simply because you voluntarily choose to receive scheduled services from an out-of-network provider at a freestanding physician or other health care professional's office that is not a hospital outpatient department.

 

Because Mensana Collaborative is an out-of-network, fee-for-service outpatient practice, you may be responsible for Mensana Collaborative's established charges regardless of the amount your health plan reimburses you. Please review Mensana Collaborative's Service Fee Schedule and Financial Policy for information about fees, payment, and out-of-network reimbursement.

 

If you are uninsured or are not using health insurance to pay for your care, you may also have the right to receive a Good Faith Estimate of expected charges under the No Surprises Act.

 

CALIFORNIA PROTECTIONS

California law provides additional protections against certain forms of balance billing, including protections that may apply when an enrollee receives covered services from an out-of-network provider at an in-network facility. The protections available to you depend on factors including the type of health coverage you have, the services you receive, the setting in which you receive them, and the laws that regulate your health plan.

 

If you believe you have been improperly balance billed, you may contact the California Department of Managed Health Care or California Department of Insurance, as applicable to your health coverage.

 

IF YOU BELIEVE YOUR RIGHTS HAVE BEEN VIOLATED

If you believe you have been improperly billed or that your rights under the No Surprises Act have been violated, you may contact the federal No Surprises Help Desk at 1-800-985-3059 or use the Centers for Medicare & Medicaid Services' No Surprises resources. CMS continues to identify this number as the federal contact for No Surprises Act assistance.

 

You may contact Mensana Collaborative if you have questions about a bill you received from the Practice:

Mensana Collaborative
3771 Rio Rd, Suite 111
Carmel, CA 93923
831.293.7300
contact@mensanacollab.com