Good Faith Estimate (For self-pay/out-of-network and uninsured clients)

In compliance with the No Surprises Act that went into effect on January 1, 2022, all healthcare providers including therapists and psychiatrists are required to notify clients of their federal protections and rights against “surprise billing.” This act protects you from unexpected medical bills. The No Surprises Act requires me to inform you when services are rendered by an out-of-network therapist, if you choose not to use insurance or are uninsured. If either of these are applicable to you, I am required to provide a “Good Faith Estimate” of the cost of services.

If your out-of-network cost will be $150 per session (weekly), take 150 x 48 weeks per year = approximately $7,200 (This cost may be lower due to practice closures for Holidays/vacations). If you engage in bi-weekly sessions, take 150 x 26 weeks per year = approximately $3,900.

Disclaimers & Client Rights

This Good Faith Estimate shows the costs of services that are reasonably expected for your mental health care needs. This estimate is based on information known at the time and is not a binding contract. You are not obligated to receive services from Empowered Emotions Counseling. If you receive a bill that is at least $400 more than this estimate, you have the right to dispute the bill. You may contact me at info@empoweredemotionscounseling.com if the billed charges are higher than expected and to request an update or explanation.

It can be challenging to estimate length of treatment, because you have the right to decide for how long to engage in services. Together, we can evaluate how many sessions (weekly, bi-weekly) you will need based on presenting concerns, finances, scheduling, etc. It may take 1-2 sessions to establish a diagnosis for insurance reimbursements.

In addition, the Good Faith Estimate does not include non-clinical services such as late cancellations, no shows, responses to subpoenas, court fees, and documentation requests (like an emotional animal support letter),.

Down below are the costs of services for self-pay/out-of-network clients:

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.

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. The Illinois Department of Insurance, Office of Consumer Health Insurance at (877) 527- 9431.