Good Faith Estimate for Uninsured and Cash-pay Clients
This Good Faith Estimate (GFE) shows the costs of items and services that are reasonably expected for health care needs of uninsured or cash-pay clients. The estimate does not include any unknown or unexpected costs that may arise during treatment. Uninsured or cash-pay clients will receive a more detailed GFE before treatment. Clients using health insurance to pay for treatment are required to pay the contracted rate with their insurance company.
The cost of an initial 50-minute psychotherapy assessment (in-person or via telehealth) is $150 for a Licensed or Associate Mental health provider and $125 for Graduate Level Student interns. The cost of a 50-minute psychotherapy visit (in-person or via telehealth) is $125 for a Licensed or Associate mental health provider and $100 for Graduate Level Student Interns.
The frequency and duration of psychotherapy visits are based on the individual needs of the client.
Throughout your treatment, the provider may recommend additional items or services as part of your treatment that is not reflected in this estimate. These would need to be scheduled separately with your consent and the understanding that any additional service costs are in addition to the Good Faith Estimate.
If your needs change during treatment, your provider should supply a new, updated Good Faith Estimate to reflect the changes to treatment, and the accompanying cost changes.
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.
The Good Faith Estimate is not a contract between provider and client and does not obligate or require the client to obtain any of the listed services from the provider. 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.
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.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call HHS at (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 or call (800) 985-3059.