Good Faith Estimate

Under the No Surprises Act, healthcare providers need to give patients who don’t have insurance or who are not using insurance a “good faith 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 psychotherapy and related costs like psychological assessments, client requests for services outside of session time (for letters, phone calls, coordination of care with ancillary providers, etc.)

Calm-Mind Therapy, LLC will give you a Good Faith Estimate in writing at least 1 business day before you begin services. You can also ask Calm-Mind Therapy, LLC 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.

Estimate of Costs

Megan Matusky’s therapy services are billed at the following rates:

  • 90834 - Psychotherapy, 45 minutes ($180)

  • 90847 –Family psychotherapy, conjoint psychotherapy with the patient present ($215)

  • 90846 - Family psychotherapy without the patient present, 50 minutes ($215)

  • 90847 - Family psychotherapy, conjoint psychotherapy with the patient present, Couples Therapy ($215)

  • 90853 - Group Therapy ($50)

Emily Earley’s therapy services are billed at the following rates:

  • 90834 - Psychotherapy, 45 minutes ($150)

  • 90847 –Family psychotherapy, conjoint psychotherapy with the patient present, couples therapy ($185)

  • 90846 - Family psychotherapy without the patient present, 50 minutes ($185)

  • 90847 - Family psychotherapy, conjoint psychotherapy with the patient present, Couples Therapy ($185)

  • 90853 - Group Therapy ($50)

Master’s Level Therapists Under Supervision bill at the following rates:

  • 90834 - Psychotherapy, 45 minutes ($120)

  • 90847 –Family psychotherapy, conjoint psychotherapy with the patient present ($150)

  • 90846 - Family psychotherapy without the patient present, 50 minutes ($150)

  • 90847 - Family psychotherapy, conjoint psychotherapy with the patient present, Couples Therapy ($150)

  • 90853 - Group Therapy ($50)

Graduate Therapists

Graduate Assistant Therapists bill at a set-your-own-rate scale with $60 as the max rate:

  • 90834 - Psychotherapy, 45 minutes (Max $60)

  • 90847 – Family psychotherapy, conjoint psychotherapy with the patient present (Max $60)

  • 90846 - Family psychotherapy without the patient present, 50 minutes (Max $60)

  • 90847 - Family psychotherapy, conjoint psychotherapy with the patient present, Couples Therapy (Max $60)

  • 90853 - Group Therapy ($30)

It is important to note that ultimately your provider will collaborate with you throughout your treatment process to determine how many sessions and/or services you may need to receive the greatest benefit based on your diagnosis(es)/presenting clinical concerns.

Disclaimer

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created, and does not include any unknown or unexpected costs that may arise during treatment.

In its current form, the No Surprises Act requires providers to assign a diagnosis before the first service is rendered. Calm-Mind Therapy, LLC follows standards of professional Codes of Ethics which deem this to be unethical. To comply with the law, Calm-Mind Therapy, LLC uses a generic billable diagnostic code that will change with proper assessment and professional services. Your care and ethical standards are important to us.

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.

Throughout your treatment, the provider may recommend additional items or services as part of your treatment that are 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.

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.

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.