navigating complexity, building resilience

Middleton Psychology Services, LLC

No Surprises Act Good Faith Estimate Information

Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges.
This form may be used by the health care providers to inform individuals who are not enrolled in a plan or coverage or a Federal health care program (uninsured individuals), or individuals who are enrolled but not seeking to file a claim with their plan or coverage (self-pay individuals) of their right to a “Good Faith Estimate” to help them estimate the expected charges they may be billed for receiving certain health care items and services. Information regarding the availability of a “Good Faith Estimate” must be prominently displayed on the convening provider’s and convening facility’s website and in the office and on-site where scheduling or questions about the cost of health care occur.

At our current rate of $50 per unit of 15 minutes, if psychotherapy continues on a once weekly 53-minute session basis for an entire year, the cost of services will be $10,500.00 for the whole year.  Of course, therapy may not go for an entire year and that will be a determination you make in partnership with your therapist.  If you do not have insurance or choose not to bill your insurance, you will be expected to cover this out of pocket.  MPS has contractual agreements with CareFirst, FirstChoice, and Medicare for reduced rates.  If you use one of these health insurance providers, your out of pocket costs will vary depending on the specifics of your individual plan which may include deductibles and copays; those costs to you invariably prove substantially less than the annual rate cited above, please review your policy to see what these may be.  


NOTE: The information provided in these instructions is intended only to be a general informal summary of technical legal standards. It is not intended to take the place of the statutes, regulations, or formal policy guidance upon which it is based. Readers should refer to the applicable statutes, regulations, and other interpretive materials for complete and current information.
[CMS Link]

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost


Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.


You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.


Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or 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​.