Good Faith Estimates for Therapy: What Self-Pay Clients Should Know

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Who this protection is for

Paying for therapy yourself can feel like signing up for an open-ended bill. The No Surprises Act gives you a tool for that worry: a Good Faith Estimate, a written list of the charges a provider expects for your care. It is meant for people who are uninsured and for people who are self-pay.

Self-pay does not mean you have no insurance. Under the federal rules, you count as self-pay when you have coverage but are not seeking to have a claim submitted to your plan for that service. CMS says that when a person has coverage, the provider must ask whether they want a claim submitted. If not, the person is treated as self-pay for the estimate. The practice's insurer pages note that self-pay clients can ask Mountainside for a Good Faith Estimate before care begins.

Two limits are worth knowing. CMS says you will not get an estimate during emergency care. And each provider gives its own estimate, so if you see a therapist at one practice and a prescriber somewhere else, ask each of them for one.

When you should get it

CMS sets clear timing rules, counted in business days. You do not need to use the words "good faith" to ask, and CMS tells providers to treat any discussion or question about the cost of care as a request for an estimate.

• Scheduled 3 to 9 business days ahead: you should get the estimate within 1 business day of scheduling.
• Scheduled 10 or more business days ahead: you should get it within 3 business days of scheduling.
• You ask before scheduling: you should get it within 3 business days of asking.
• Scheduled 0 to 2 business days ahead: CMS says you are not entitled to an estimate for that booking, though you can ask about future sessions.
• Format: in writing, on paper or electronically, in the way you prefer. An electronic copy must be one you can save and print.

Where you will hear about it

CMS requires providers to make information about Good Faith Estimates easy to find: on their website, in the office, and wherever scheduling or cost questions happen. They must also mention it when you schedule or ask about cost. If you have scheduled and have not received an estimate, you can ask for one in writing.

What a Good Faith Estimate lists

Estimates do not all look the same, because CMS does not require one exact form. They must include the same core information, though. Expect to see a description of the main service, such as individual psychotherapy, and an itemized list of what the provider expects to furnish for that period of care, with service codes and the expected charge for each item.

The estimate also lists the provider's name, National Provider Identifier and location. It includes diagnosis codes only where one is required. CMS notes that providers do not need a diagnosis code before one has been determined, such as for an initial evaluation. It must also carry several disclaimers: the figures are an estimate, actual charges may differ, it is not a contract and does not require you to get care from that provider, and you have the right to dispute a bill that is much higher. CMS also requires the estimate to say that starting a dispute will not hurt the quality of your care.

How estimates work for ongoing therapy

Therapy is usually a series of sessions, not a single visit, and nobody can know the exact number at the start. CMS addresses this directly. For recurring services such as periodic counseling, a provider may issue one estimate for the series instead of one for every session.

That single estimate must spell out the expected scope in plain terms, such as the timeframe, how often you will meet and the total number of sessions. Its scope cannot be longer than 12 months. If sessions are expected to continue past 12 months, you should get a new estimate. You should also get a new one if the provider expects the scope to change, for example a new frequency, an added group or different charges. That new estimate is due no later than 1 business day before the changed services, and the provider must explain what changed.

Read the estimate the way you would read a lease. Check that the session length, frequency and total match what you discussed. If you plan to add a skills group or family sessions later, expect those to appear on a new estimate.

If the bill is much higher than the estimate

Keep your estimate somewhere safe. CMS suggests also taking a photo of it, and when bills arrive, comparing them to the estimate. Providers must keep the estimate as part of your medical record and give you a copy of any estimate from the last 6 years if you ask.

If a provider's total bill is 400 dollars or more above the total on that provider's estimate, you may be able to use the federal patient-provider dispute resolution process. You must start within 120 days (about 4 months) of the date on your initial bill, and you need a copy of the written estimate and the bill. An independent third party reviews the case and decides what you should pay. There is a small nonrefundable administrative fee to start. While a dispute is active, CMS says the provider cannot send the bill to collections or threaten to. The CMS dispute page (opens in a new tab) has the current steps.

Superbills, out-of-network benefits and next steps

A Good Faith Estimate lists what the provider expects to charge you. It does not predict what any insurer might pay back. If you plan to submit a superbill for out-of-network reimbursement, treat the estimate as your expected cost before reimbursement, and check your benefits separately. The insurance and pricing page explains superbills and how to check out-of-network benefits, and the Aetna page shows how reimbursement is worked out. Our guide to paying for therapy: insurance vs self-pay compares the options side by side.

Because CMS defines self-pay by whether you want a claim submitted to your plan, tell a new therapist early how you plan to pay. A free consultation is a natural time to raise cost. Your written Colorado disclosure statement should also describe the fee structure. When you are ready, you can request a consultation.

Frequently asked questions