Medicare, Medicaid, and Insurance Notice

IMPORTANT NOTICE

Medicare, Medicaid, and Insurance Notice

Required information for patients enrolled in Medicare, Medicaid, or other health insurance programs who are considering care at AvaOne. Please read this notice carefully before scheduling.

AvaOne Is a Cash-Pay Practice

AvaOne Heart and Wellness is a cash-pay medical practice. We do not participate with any health insurance network, including private commercial insurance, Medicare, Medicaid, TRICARE, or any other government-funded health insurance program. We do not submit claims to insurance companies on behalf of patients. We do not accept assignment from any insurance program. We do not provide medical billing services beyond the receipts our patients receive for services rendered.

Our cash-pay structure allows our physicians to spend significantly more time with each patient than insurance-driven medicine typically permits, to order and interpret the advanced diagnostic testing that conventional insurance often does not reimburse for, and to deliver the structured lifestyle medicine and ongoing physician relationship that defines the AvaOne experience. We believe this structure better serves the patients we are designed to serve. We also recognize that the cash-pay structure raises important questions for patients enrolled in Medicare, Medicaid, and other insurance programs. This notice addresses those questions.

Information for Patients Enrolled in Medicare

If you are enrolled in Medicare (Part A, Part B, Part C / Medicare Advantage, or Part D), it is important to understand how AvaOne’s cash-pay structure interacts with your Medicare coverage.

AvaOne’s providers have elected to operate outside of the Medicare program. This means that services provided at AvaOne are not covered by Medicare, will not be submitted to Medicare for payment, and are paid for entirely by the patient. Medicare beneficiaries who receive services at AvaOne are responsible for paying the full cost of those services at the time they are rendered. AvaOne does not provide Advance Beneficiary Notices (ABNs) because AvaOne does not bill Medicare under any circumstances.

Patients enrolled in Medicare who wish to receive care at AvaOne will be asked to sign a private contract acknowledging that the services they receive at AvaOne are not covered by Medicare, that they understand AvaOne does not bill Medicare, that they are responsible for paying for these services in full, and that they cannot submit these charges to Medicare for reimbursement. This private contract is a legal requirement under federal Medicare rules for physicians providing services to Medicare beneficiaries outside of the Medicare program.

It is important to understand that receiving cash-pay care at AvaOne does not affect your Medicare coverage for services you receive elsewhere. Your Medicare coverage remains in effect for services provided by your primary care physician, specialists who accept Medicare, hospitals, and other Medicare-participating providers. AvaOne is in addition to, not in place of, your regular Medicare-covered care. We encourage all Medicare beneficiaries who become AvaOne patients to continue their relationships with their Medicare-participating primary care physician and specialists.

Information for Patients Enrolled in Medicaid

If you are enrolled in Medicaid, including New Jersey Medicaid or any other state Medicaid program, federal and state regulations affect whether you can receive services at AvaOne. Medicaid programs have specific rules regarding payment for medical services that differ from Medicare and from private insurance, and these rules vary by state.

In general, Medicaid beneficiaries should consult with their state Medicaid program and, where applicable, their managed care organization before receiving cash-pay medical services from a non-participating provider. Some Medicaid programs prohibit beneficiaries from paying cash for services that would otherwise be available through Medicaid-participating providers. Other

programs permit cash-pay arrangements under specific circumstances. The rules vary significantly by state and by program type.

AvaOne does not provide legal or regulatory advice to patients regarding their Medicaid coverage. Patients enrolled in Medicaid who are considering care at AvaOne should consult their state Medicaid agency, their managed care organization, or qualified legal counsel before scheduling services. AvaOne will request acknowledgment of these considerations from patients enrolled in Medicaid before providing services. If you have questions about whether your Medicaid coverage permits cash-pay arrangements at AvaOne, please contact our office at (973) 679-6949.

Information for Patients with Commercial Health Insurance

If you have commercial health insurance (employer-sponsored or individual coverage from a commercial insurance company), AvaOne does not participate with any commercial insurance network. We do not submit claims to commercial insurance companies. We do not accept assignment of benefits from commercial insurance plans. Services received at AvaOne are paid for in full by the patient at the time of service.

Some commercial health insurance plans offer out-of-network benefits that may provide partial reimbursement for services received from non-participating providers. The availability, level, and conditions of out-of-network reimbursement vary significantly by plan and are entirely between you and your insurance carrier. AvaOne does not coordinate with commercial insurance plans for out-of-network reimbursement. If your plan offers out-of-network benefits and you wish to seek reimbursement, AvaOne will provide you with a detailed receipt (sometimes called a superbill) that contains the information typically required for out-of-network claim submission. Whether your plan will reimburse any portion of your AvaOne expenses, and how much, is determined entirely by your insurance carrier.

We strongly encourage patients with commercial insurance to verify their out-of-network benefits with their insurance carrier before scheduling at AvaOne if reimbursement is important to their decision. AvaOne does not guarantee, predict, or otherwise represent that any commercial insurance plan will reimburse any portion of patient expenses at AvaOne.

HSA and FSA Payments

AvaOne accepts payment through Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs) for services that qualify as medical expenses under IRS rules. Most preventive cardiology and lifestyle medicine services provided at AvaOne qualify as medical expenses under IRS Publication 502. Patients are responsible for determining whether specific services qualify under their HSA or FSA plan and IRS rules.

AvaOne provides itemized receipts that contain the information typically required for HSA and FSA reimbursement and substantiation. We do not provide tax advice or substantiation guarantees. Patients with questions about whether specific services qualify under their HSA or FSA plan should consult their plan administrator or a qualified tax professional.

Required Acknowledgments Before Scheduling

Before receiving services at AvaOne, all patients are asked to acknowledge their understanding of our cash-pay structure and the information in this Notice. Patients enrolled in Medicare or Medicaid are asked to sign specific acknowledgment documents that reflect the regulatory requirements applicable to their coverage. These acknowledgments are required because federal and state rules governing care of patients with government health insurance differ from rules governing care of patients with commercial insurance, and because we want to ensure that every patient understands the financial arrangement before any services are provided.

- Acknowledgment that AvaOne is a cash-pay practice and does not participate with any insurance network
- Acknowledgment that services received at AvaOne are paid for in full by the patient at the time of service
- Acknowledgment that AvaOne does not submit claims to any insurance company or government program
- For patients with Medicare: signed private contract under federal Medicare rules

- For patients with Medicaid: signed acknowledgment of state Medicaid program implications
- For patients with commercial insurance: acknowledgment that out-of-network reimbursement is not guaranteed and is the responsibility of the patient and their insurance carrier
- Acknowledgment that the patient has been encouraged to continue their relationship with their primary care physician and other insurance-participating providers

Patient Rights and Practice Commitments

AvaOne is committed to transparent, ethical, and patient-centered care. As part of that commitment, every patient at AvaOne has the right to receive clear pricing information before any service is provided, to ask questions about the financial arrangement at any time, to decline services after receiving cost information, and to discontinue care at any time without prejudice.

AvaOne does not offer discounts, waivers, or other inducements to Medicare or Medicaid beneficiaries that would not also be available to other patients. Our pricing is the same for all patients regardless of their insurance status, age, or any other protected characteristic. We do not waive copays, deductibles, or other patient cost-sharing for Medicare or Medicaid patients because doing so would violate federal anti-kickback and beneficiary inducement rules.

If you have any questions about this Notice, our cash-pay structure, or how it interacts with your specific insurance coverage, please contact our office at (973) 679-6949 before scheduling

services. We are happy to discuss your situation. We cannot provide legal or regulatory advice about your specific insurance coverage, but we can explain our practice’s structure clearly and help you decide whether AvaOne is the right fit for your situation.

Insurance and Payment FAQs

Frequently Asked Questions

Can Medicare patients pay cash for medical care?

Yes, Medicare beneficiaries can receive cash-pay care from physicians who have elected to operate outside of the Medicare program, provided that specific federal rules are followed. Under these rules, the physician must enter into a written private contract with the Medicare beneficiary that acknowledges the services are not covered by Medicare, that the physician will not bill Medicare for the services, and that the beneficiary is responsible for paying for the services in full and cannot submit them to Medicare for reimbursement. AvaOne follows these federal requirements for all Medicare beneficiaries who choose to receive care at our practice. Patients enrolled in Medicare who wish to schedule care at AvaOne should request a copy of the private contract document during their initial scheduling call so that they can review it before their first visit.

If I have Medicare, will my AvaOne care affect my regular Medicare coverage?

No. Receiving cash-pay care at AvaOne does not affect your Medicare coverage for services you receive from other providers. Your Medicare coverage remains in full effect for services provided by your primary care physician, by specialists who accept Medicare, by hospitals, and by other Medicare-participating providers. AvaOne is in addition to, not in place of, your regular Medicare-covered care. We strongly encourage all Medicare beneficiaries who become AvaOne patients to continue their relationships with their Medicare-participating primary care physician and specialists. AvaOne coordinates with these providers when appropriate, with your permission, to ensure that your overall care is integrated.

Will my commercial insurance reimburse me for AvaOne services?

Some commercial insurance plans offer out-of-network benefits that may provide partial reimbursement for services received from non-participating providers like AvaOne. The

availability, amount, and conditions of out-of-network reimbursement vary significantly by plan and are entirely between you and your insurance carrier. AvaOne does not submit claims to commercial insurance and does not coordinate out-of-network reimbursement. If your plan offers out-of-network benefits and you wish to seek reimbursement, we will provide a detailed receipt or superbill that contains the information typically required for out-of-network claim submission. We strongly recommend that you verify your specific out-of-network benefits with your insurance carrier before scheduling at AvaOne if reimbursement is important to your decision.

Acknowledgment of This Notice

By scheduling services at AvaOne, you acknowledge that you have had the opportunity to read this Medicare, Medicaid, and Insurance Notice, that you understand AvaOne is a cash-pay practice that does not participate with any insurance network, that you are responsible for paying for services in full at the time they are rendered, and that AvaOne does not submit claims or coordinate reimbursement with any insurance program. For patients enrolled in Medicare or Medicaid, you acknowledge that you will be asked to sign additional documents specific to your coverage type before services are provided.

If you have questions about this Notice or how it applies to your specific situation, please contact our office at (973) 679-6949 before scheduling services. For questions about your insurance coverage specifically, please contact your insurance carrier, your state Medicaid agency (if applicable), or qualified legal counsel.

IMPORTANT NOTICE