No Surprise Act
WHO Does this impact?
Currently, clients who are receiving services from an out-of-network provider or self-pay clients.
wHAT is the No Surprise Act?
Effective January 1, 2022, the No Surprises Act (passed by Congress as part of the Consolidated Appropriations Act of 2021) is designed to protect clients from surprise bills by holding clients liable only for in-network cost-sharing amounts for the following situations:
- Emergency services at out-of-network facilities OR
- Out-of-network providers at in-network facilities
Additionally, the act requires that clients receive a Good Faith Estimate (GFE) for the cost of care if they are:
- Uninsured (don’t have insurance) OR
- Are paying for services 100% out-of-pocket.
WHAT is a Good Faith Estimate (GFE)?
If you are uninsured or choose to pay for services out-of-pocket, you are entitled to receive a “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you.
While it is not possible for our clinicians to know (in advance) how many sessions may be necessary or appropriate for a given person, the GFE provides an estimate of the cost of services to be provided. Your total cost of services will depend upon the number of sessions you attend, your individual circumstances, and the type and amount of services that are provided to you. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified in the GFE. Furthermore, the GFE is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of visits. The number of visits that are appropriate for your case, and the estimated cost for those services, depend on your needs and what you agree to in consultation with your clinician. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.
If you attend therapy for a longer period, your total estimated charges will increase according to the number of visits and length of treatment.
This GFE shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The GFE 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.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a healthcare facility that isn’t in your health plan’s network.
- “Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
- “Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You are never required to give up your protection from balanced billing.
You also aren’t required to get care out-of-network.
You can choose a provider or facility in your plan’s network.
If you are billed for more than your Good Faith Estimate, you have the right to dispute the bill.
You may contact the health care provider or facility to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, 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 Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-800-985-3059.