The No Surprises Act and Your Good Faith Estimate
Under the No Surprises Act, if you do not have insurance or choose not to use it, a provider must usually give you a Good Faith Estimate of expected charges when you schedule care at least 3 business days ahead or ask for one. If a bill is at least $400 more than that estimate, you can dispute it.
Key points
A Good Faith Estimate is a written list of expected charges for people who are uninsured or not using insurance.
You get one when you schedule care at least 3 business days in advance, or any time you ask.
If a provider bills at least $400 more than its estimate, you can start a federal dispute within 120 calendar days of the initial bill.
Keep your estimate. You cannot use the dispute process without it.
What is a Good Faith Estimate?
A Good Faith Estimate is a document from a health care provider or facility that shows the expected charges for the care you have scheduled. The Centers for Medicare & Medicaid Services (CMS) says it must include an itemized list with specific details and expected charges for the items and services related to your care.
The rule is written for health care providers and facilities in general, and counseling practices are included. That is why you will see a notice about it at a therapist's office and on the practice's website.
The estimate is not a bill. Its purpose is to let you see the likely cost before your care begins, and to give you something to compare against the bill you receive later.
Who has the right to a Good Faith Estimate?
CMS describes the right as belonging to people who are not using health insurance to pay for their care. That covers two groups: people who do not have insurance, and people who have insurance but choose not to use it for a particular service, often called self-pay.
If you are using your insurance for therapy, this estimate rule is not the one that applies to you. Your costs are set by your plan's deductible, copay and coverage rules. Our guide on how to check mental health insurance benefits covers the questions to ask your plan.
When should you get a Good Faith Estimate?
Timing depends on how far ahead you schedule. These are the time frames CMS publishes for consumers.
Scheduled 3 to 9 business days ahead. You should get the estimate within 1 business day after scheduling.
Scheduled 10 or more business days ahead. You should get the estimate within 3 business days after scheduling.
You ask for an estimate. You can ask before you schedule anything. The provider must give it to you within 3 business days.
Scheduled fewer than 3 business days ahead. The scheduling rule does not entitle you to an estimate, and estimates are not given during emergency care. You can still ask what the visit will cost.
What should a Good Faith Estimate include?
CMS says a good faith estimate should list the expected charges for the health care items and services you are scheduled to receive. A few points are worth knowing:
It should be in writing. You can get it in the way you prefer, printed on paper or emailed.
It covers a single provider or facility. If more than one provider is involved in your care, ask each one for its own estimate.
It may not include items or services your provider did not anticipate before care began, or services that are scheduled separately.
You do not need to use the exact words "good faith estimate" when you ask.
If you scheduled care and have not received one, ask for it in writing. If you lose it, ask for a new copy.
What if your bill is higher than the estimate?
CMS runs a patient-provider dispute resolution process for this situation. You can use it when a bill from one provider or facility is at least $400 more than the Good Faith Estimate from that same provider or facility.
There are conditions. You must not have used insurance to pay for the care, the care must be dated January 1, 2022 or later, you need your Good Faith Estimate, and your initial bill must be dated within the last 120 calendar days, which is about four months.
There is a $25 administrative fee, and it is non-refundable. The dispute does not start until the fee is paid. CMS says that if the decision goes your way, the $25 is deducted from what you owe the provider.
While a dispute is open, your provider cannot move the bill into collections or threaten to, and cannot take action against you for disputing it. If the bill is already in collections, collection efforts must pause until the dispute ends.
Before starting a formal dispute, it is reasonable to call the billing office and ask about the difference. The 120 days are counted from the date on your initial bill, so keep an eye on the calendar while you sort it out.
What you need to start a dispute
A copy of your Good Faith Estimate, digital or paper
A copy of your bill
Your provider's contact information
Payment for the $25 fee
Questions: the CMS No Surprises Help Desk at 1-800-985-3059
How Balanced Life handles Good Faith Estimates
If you are paying for counseling yourself at Balanced Life Counseling Services, you have the right to a Good Faith Estimate, and you can ask us for one at any time. Our No Surprises Act notice has the practice's full statement.
Our self-pay fees are posted on the insurance and fees page: $150 for an initial assessment, $130 for a 45 to 50 minute individual therapy session, $65 for a 30 minute session, $130 for family therapy and $35 for group therapy. We also offer a Sliding Fee Program based on household income and family size.
To request an estimate or ask about costs before your first visit at our Salisbury or Bethesda office, contact us.
Frequently asked questions
Do I get a Good Faith Estimate if I am using my insurance?
The Good Faith Estimate described here is for people who are not using health insurance to pay for care, either because they are uninsured or because they choose to self-pay. If you are using insurance, your costs depend on your plan. Call the number on your insurance card to check your deductible, copay and covered services before your first appointment.
How much higher does a bill have to be before I can dispute it?
According to CMS, you can use the patient-provider dispute resolution process when one provider or facility bills you at least $400 more than the Good Faith Estimate it gave you. You must start the dispute within 120 calendar days of the date on your initial bill, and there is a $25 non-refundable administrative fee.
What if I never received a Good Faith Estimate?
Ask your provider for one in writing. CMS notes that you cannot use the dispute process without an estimate. If you think you should have received one and did not, you can submit a complaint to CMS or call the No Surprises Help Desk at 1-800-985-3059. You are still responsible for paying your bill.
Can ongoing therapy sessions be covered by one estimate?
Ask the provider how its estimate handles repeat visits. The CMS consumer pages we reviewed explain that an estimate lists expected charges for scheduled items and services from a single provider, and that separately scheduled services may not be included. If your treatment plan changes, it is reasonable to ask for an updated estimate.
Sources
If you are in crisis or thinking about suicide, call or text 988 (Suicide and Crisis Lifeline). In an emergency, call 911.