NO SURPRISE ACT/GOOD FAITH ESTIMATE NOTICE
You have the right to receive a “Good Faith Estimate” explaining how much your medical 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 bill for medical items and services. [If you plan to submit for reimbursement to your insurance, a GFE is not required.]
• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or 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
Sample Good Faith Estimate
Brief Explanation of Estimate:
The estimate below is an estimated range of costs that is likely for most clients. Until I do an initial evaluation and we start to work together, I will not have a clear picture of your specific diagnosis, presenting problems, and needs. I typically see clients for 10-40 sessions per year for a total cost of $1,350-6,000 annually. But in many cases a client’s presenting concerns and diagnoses may be more complicated, and may require additional sessions during the time covered by this estimate.
Standard Rates for Services:
These are my standard rates for services. Rates subject to change and price reduction based on individual client needs based on income or as determined by Effort and Ease Counseling, LLC.
Service 1:
Initial Evaluation: 90791/90791-95
Cost: $160
Service 2:
Psychotherapy, 45 minutes: 90834/90834-95
Cost: $135
Service 3:
Psychotherapy, 60 minutes: 90837/90837-95
Cost: $150
Details of the Estimate:
The following is a detailed list of expected charges for weekly psychological and counseling services at the above standard rates. This estimate does not account for reduced rates in services, biweekly, monthly, or missed appointments, holidays, or other lapses in service. The estimated costs are valid for 12 months from the date of this Good Faith Estimate, unless I send you an updated Estimate.*
Estimated Total Costs:
| Number of Weekly Sessions | Estimated Charges 45 Minute Session | Estimated Charges 60 Minute Session |
|---|---|---|
| One Session | $135 | $160 |
| 13 Sessions (Approx. 3 Months) | $1,755 | $2,080 |
| 26 Sessions (Approx. 6 months) | $3,510 | $4,160 |
| 39 Sessions (Approx. 9 months) | $5,265 | $6,240 |
| 52 Sessions (Approx. 12 Months) | $7,020 | $8,320 |
Disclaimer:
This Good Faith Estimate shows the costs of services that are reasonably expected for the necessary services to address your mental health care needs. The estimate is based on the information known to Emily Claire Roberts at time of completing the estimate.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
If you are billed for $400 more (per provider) than this Good Faith Estimate (GFE), you have the right to dispute the bill.
You may contact Emily Claire Roberts, LMHC to let them know the billed charges are at least $400 higher than the GFE. You can ask them to update the bill to match the GFE, ask to negotiate the bill, or ask if there is financial assistance available.
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 GFE. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
To learn more and get a form to start the process, go to:
http://www.cms.gov/nosurprises or call CMS at 1-800-985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit http://www.cms.gov/nosurprises or call CMS at 1-800-985-3059 .
This GFE is not a contract. It does not obligate you to accept the services listed above.
Keep a copy of this Good Faith Estimate (GFE) in a safe place or take pictures of it. You may need it if you are billed more than $400 than the estimate provided above.
Effort and Ease Counseling, LLC 