Good Faith Estimate
TCA No Surprises Act Notice and Good Faith Estimate
THE NO SURPRISES ACT
STANDARD NOTICE AND CONSENT DOCUMENTS
(OMB Control Number: 0938-1401)
The purpose of this document is to let you know about your protections from unexpected medical bills. It also asks whether you would like to give up those protections and pay more for out-of-network care.
If your plan covers the item or service you’re getting, federal law protects you from higher bills:
- When you get emergency care from out-of-network providers and facilities, or
- When an out-of-network provider treats you at an in-network hospital or ambulatory surgical center without your knowledge or consent.
Ask your healthcare provider or patient advocate if you need help knowing if these protections apply to you.
If you sign this form, you may pay more because:
- You are giving up your protections under the law.
- You may owe the full costs billed for items and services received.
- Your health plan might not count any of the amount you pay towards your deductible and out-of-pocket limit. Contact your health plan for more information.
You shouldn’t sign this form if you didn’t have a choice of providers when receiving care. For example, if a doctor was assigned to you with no opportunity to make a change.
Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility. If there isn’t one, your health plan might work out an agreement with thisprovider or facility, or another one.
Prior authorization or other care management limitations
Except in an emergency, your health plan may require prior authorization (or other limitations) for certain items and services. This means you may need your plan’s approval that it will cover an item or service before you get them. If prior authorization is required, ask your health plan about what information is necessary to get coverage.
Take a picture and/or keep a copy of this form.
It contains important information about your rights and protections.
The amount below is only an estimate; it isn’t an offer or contract for services. This estimate shows the full estimated costs of the items or services listed. It doesn’t include any information about what your health plan may cover or if a sliding fee scale has been negotiated. This means that the final cost of services may be different than this estimate.
Contact your health plan to find out how much, if any, your plan will pay.
This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.
The fee for a 53 -minute psychotherapy visit (in person or via telehealth) is $165 for independently licensed therapists, $120 for associate licensed therapists at $70 for student therapists, unless a sliding scale rate was agreed upon. Most clients will attend one psychotherapy visit per week, but the frequency of psychotherapy visits that are appropriate in your case may be more or less than once per week, depending upon your needs. Based on this per visit fee cited above, the following are expected charges of psychotherapy services:
Number of Weeks
Total estimated charges for 53 min session per week w independent therapist (90 min)
Total estimated charges for 53 min session per week w associate therapist (90 min)
Total estimated charges for 53 min session per week w student therapist (90 min)
1 Week of Service
$165 ($247.50)
$120 ($180)
$70 ($105)
13 Weeks of Service (Approx. 3 Months)
$2,145 ($3,217.5)
$1,560 ($2,340)
$910 ($1,365)
26 Weeks of Service (Approx. 6 months)
$4,290 ($6,435)
$3,120 ($4,680)
$1,820 ($2,730)
39 Weeks of Service (Approx. 9 months)
$6,435 ($9,652.5)
$4,680 ($7,020)
$2,730 ($4,095)
52 Weeks of Service (Approx. 12
Months)
$8,580 ($12,870)
$6,240 ($9,360)
$3,640 ($5,460)
No show or late cancellation fees:
Independently licensed and Associate therapists: $50
Intern therapists: $25
Ketamine-Assisted Psychotherapy (KAP)
If you are receiving Ketamine Assisted Psychotherapy you will need a complete a 90 min medical evaluation and at least one preparation session with a licensed therapist. You will have to pay for the medication out of pocket. You will then have an induction session followed by a integration session and follow that model of medicine/integration session. After 6, you will be reevaluated to see if you would be interested and benefit in additional sessions.
Below is the breakdown of cost for KAP based of our 6 session model for either Individual or group.
Individual KAP utilizing Intramuscular injection:
Psychiatric evaluation:250
Prep session(s): 150
KAP session(s): 470
Integration sessions(s): 150
Estimated total for 6 sessions: $4,120
Individual KAP utilizing Self-Administration troche:
Psychiatric Evaluation: 250
Prep session(s): 150
lozenges: 60
KAP session(s): 350
Integration session (s): 150
Estimated total for 6 sessions: $3,460
Total for Group KAP (at an estimated 6 sessions):
Psychiatric evaluation:250
Group Prep session: 45
KAP session(s): 170
Group integration sessions: 45
Estimated total for 6 sessions: 1,585
No Show or Late Cancellation fees
Psychiatric evaluation for KAP: $100
KAP individual appointment (first time): $150
KAP individual appointment (subsequent sessions): full rate
KAP group medicine session: $50
KAP group integration session: $50
Psychiatric Evaluation and Medication Management
Psychiatric evaluations ($250) are the intake appointments for our medical providers. After this
initial session, ongoing, consistent sessions are considered medication management ($125) and
are scheduled at a frequency the medical provider and client agree on. The rates below are based
on one week, one month, 6 months, and one year of services.
1 week
$250
1 month
$375
6 months (assuming monthly appointments)
$1,000
1 year
$1,750
No show or late cancellation fee: $85
You have a right to dispute a bill if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges). Initiating the dispute process will not adversely affect the quality of servicesrendered to you. 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. 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, 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) 368-1019.
Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.
You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate.
More information about your rights and protections Visit here for more information about your rights under federal law.