No Surprises Act
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OMB Control Number: 0938-1433. Expiration date: 11/2025
Under the Federal “No Surprises Act,” healthcare providers need to give patients who don’t have insurance or who are not using insurance a Good Faith Estimate of the bill for medical items and services. You have the right to receive a “Good Faith Estimate” of the total expected cost of any non-emergency healthcare services, including psychotherapy services. You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a 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.
Certain tax laws have created new programs that may help you pay for your therapy, including Medical Savings Accounts and Pre-Tax Flexible Spending Medical Accounts. You can also deduct the cost of therapy from your taxes if you itemize. It is a medical expense. Ask your Accountant or Compensation and Benefits Administrator if you qualify for either program.
If your insurance plan offers Out-of-Network benefits for mental health care, it may be possible to submit a request for partial reimbursement of the fees you pay for psychotherapy. If you are interested in this possibility, we are happy to provide you with the necessary form for submission. Please check with your insurance company to determine what benefits are available to you. Coaching services, support groups, workshops, and retreats are not covered by insurance companies.
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Disclaimer
A Good Faith Estimate (GFE) shows the costs of items and services that are reasonably expected for your healthcare needs for a service. The estimate is based on information known at the time the estimate was created. This GFE is only an estimate. There may be additional services or items the provider recommends that may need to be scheduled or requested separately.
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, and your bill is $400 or more for any provider or facility than your Good Faith Estimate for that provider or facility, federal law allows you to dispute the bill.
The Good Faith Estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the Good Faith Estimate.
If you are billed for more than this Good Faith Estimate, you may have the right to dispute the bill.
You may contact the health care provider or facility listed 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.
If you dispute your bill, the provider or facility cannot move the bill for the disputed item or service into collection or threaten to do so, or if the bill has already moved into collection, the provider or facility has to cease collection efforts. The provider or facility must also suspend the accrual of any late fees on unpaid bill amounts until after the dispute resolution process has concluded. The provider or facility cannot take or threaten to take any retributive action against you for disputing your bill.
There is a $25 fee to use the dispute process. If the Selected Dispute Resolution (SDR) entity reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate, reduced by the $25 fee. If the SDR entity 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 www.cms.gov/nosurprises/consumers or call 1- 800-985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800- 985-3059.
If you think you’ve been wrongly billed, contact: The Georgia Secretary of State by emailing soscontact@sos.ga.gov or calling 404-656-2817.
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.
Visit https://gov.georgia.gov/ for more information about your rights under Georgia law.
You should keep a copy of the Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.
PRIVACY ACT STATEMENT
Centers for Medicare & Medicaid Services (CMS) is authorized to collect the information on this form and any supporting documentation under section 2799B-7 of the Public Health Service Act, as added by section 112 of the No Surprises Act, title I of Division BB of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260). We need the information on the form to process your request to initiate a payment dispute, verify the eligibility of your dispute for the PPDR process, and determine whether any conflict of interest exists with the independent dispute resolution entity selected to decide your dispute. The information may also be used to (1) support a decision on your dispute; (2) support the ongoing operation and oversight of the PPDR program; (3) evaluate selected IDR entity’s compliance with program rules. Providing the requested information is voluntary. But failing to provide it may delay or prevent processing of your dispute, or it could cause your dispute to be decided in favor of the provider or facility.
