Standard Notice related to No Surprises Act 

Getting cost estimates before you get care if you’re uninsured or self-pay

Current rates for clinical services

$150 for 45-minute therapy session

$200 for 53-minute to 60-minute therapy session

Duration and frequency of sessions is determined by clinical need

These rates are scheduled to increase by $5 effective July 1, 2022

Beginning January 1, 2022, if you’re uninsured or don’t plan to submit your claim to your health plan, health care providers and facilities must provide you with a “good faith estimate” of expected charges before you get an item or service. The good faith estimate isn’t a bill. 

 

Providers and facilities must give you a good faith estimate if you ask for one, or when you schedule an item or service. It should include expected charges for the primary item or service you’re getting, and any other items or services provided as part of the same scheduled experience.

 

For example, if you’re getting surgery, the good faith estimate could include the cost of the surgery, any lab services or tests, and the anesthesia used during the operation. But in some instances, items or services related to the surgery that are scheduled separately, like pre-surgery appointments or physical therapy in the weeks after the surgery, might not be included in the estimate.

 

In 2022, the estimate isn’t required to include items and services provided to you by another provider or facility, but you can ask these providers or facilities for a separate estimate. In 2023, the provider or facility will be required to provide co-provider or co-facility cost information.

 

Note: You could be charged more than the estimate if you get additional items or services during your visit or procedure that your doctor didn’t anticipate.

 

What to expect from a good faith estimate 

 

Providers and facilities must give you:

  • Your good faith estimate before an item or service is provided, within certain timeframes.

  • An itemized list with specific details and expected charges for items and services related to your care.

  • Your good faith estimate in writing (paper or electronic). Note: A provider or facility can discuss the information included in the estimate over the phone or in person if you ask.

  • Your estimate in a way that’s accessible to you.

 

Disputing charges higher than the estimate

Once you get your good faith estimate from your provider or facility, keep it in a safe place so you can compare it to bills you get later. 

If you get the bill and the charges are at least $400 above the good faith estimate, you may be eligible to start a patient-provider dispute.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 267-225-3483.

If you believe you’ve been wrongly billed, you may contact:
1-877-881-6388
 
Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf for more information about your rights under Federal law.
 

Call 

123-456-7890 

Email 

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