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The No Surprises Act1 (NSA) protects uninsured (or private pay) individuals from many unexpectedly high medical bills. Under the law, healthcare providers need to give patients who don’t have insurance or who are not using insurance (otherwise known as private pay) an estimate of the bill for healthcare services. This was in response to the need for hospitals and emergency rooms to provide transparency with patients to avoid unexpected out of network expenses.

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However, this law pertains to all healthcare services, including mental health counseling.

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As such, you are entitled to receive a “Good Faith Estimate” of what the charges could be for counseling services provided to you. While it is not possible for a counselor to know, in advance, how many counseling sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of counseling sessions you attend, your individual circumstances, and the type and amount of services that are provided to you.

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This Good Faith Estimate is not a contract and does not obligate you to obtain any services from our counseling center. It is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of counseling visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your counselor. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

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If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. This estimate is good for 12 months from the date it is signed.

 

Disclaimer

This Good Faith Estimate does not in any way increase your agreed upon rate with your provider. Instead, it is a way to show transparency about an estimate of what you can expect to be billed for services over a period of time.

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The Good Faith Estimate shows the costs of services that are reasonably expected for your health care needs for a service. The estimate is based on information known at the time the estimate was created.

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The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. It does not cover any cancellation or no-show charges. It also does not cover last minute/crisis appointments or any other unexpected costs such as documentation/paperwork that is billable outside of service hours. These are additional services your provider will discuss with you BEFORE services take place. You can request an updated Good Faith Estimate at any time.

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If you are billed for more than this Good Faith Estimate, you have the right to dispute this bill.

You may contact your health care provider to let them know that you don't agree with what you were charged based upon your Good Faith Estimate, or if you want to change your service schedule to better fit the Good Faith Estimate. You can ask your healthcare provider to explain this estimate to you and answer any questions. You can also request an updated Good Faith Estimate at any time.

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You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.

 

There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate and nothing higher. If the agency disagrees with you and agrees with the health care provider, you will have to pay the higher amount.

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For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call (800) 368-1019.

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Please retain a copy of this Good Faith Estimate for your records. It will also be included in your medical record with your healthcare provider.