Good Faith Estimates
The "No Surprises Act" is designed to protect individuals from receiving unexpected medical and mental health bills. The "Good Faith Estimate" (GFE) section of the "No Surprises Act" is designed to help individuals understand how much they will be charged for medical and mental health services, prior to the first appointment.
You are entitled to request a Good Faith Estimate for the total expected costs of non-emergency mental health services provided by Dr. Hill in the following circumstances:
• You do not have health insurance (you are uninsured), OR
• You have health insurance, but are choosing to pay out-of-pocket (also called "self pay" or "private pay"), and will NOT be using insurance benefits or seeking reimbursement from an insurance company.
Dr. Hill is not required to provide a Good Faith Estimate in the following circumstances:
• You are planning to use insurance benefits to cover all or part of non-emergency mental health services (this includes copays, coinsurance, deductibles, and OON benefits).
• You are receiving emergency, unexpected, or unanticipated mental health services (because these services, by their nature, are unpredictable and cannot be scheduled in advance). You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
• You scheduled a service with Dr. Hill less than three (3) business days in advance of the date of service.
How can I request a Good Faith Estimate?
• You can request a Good Faith Estimate verbally or in writing. If you have questions about how much an item or service may cost, that is a good time to request a Good Faith Estimate. You do not need to use an exact or specific phrase or form.
• The Good Faith Estimate will be provided to you in writing, and it may be an electronic or hard copy. You may print electronic copies of the Good Faith Estimate if you wish.
• Make sure to save a copy or picture of your Good Faith Estimate.
How long does it take to receive a Good Faith Estimate?
• If the item or service is scheduled at least ten (10) business days in advance, the good faith estimate will be provided to you within three (3) business days.
• If the item or service is scheduled at least three (3) business days in advance, the good faith estimate will be provided to you within one (1) business day.
• If you request a Good Faith Estimate (even if nothing is scheduled yet), the estimate will be provided to you within three (3) business days.
• Dr. Hill is not required to give you a Good Faith Estimate if a service is scheduled less than three (3) business days before the appointment.
Additional important information:
• Dr. Hill may recommend additional therapy services at a later time that were not part of the initial Good Faith Estimate. If that occurs, you may request a new/updated estimate.
• Information contained within a Good Faith Estimate is only an estimate. Actual items, services, and/or charges may change or differ.
• You have the right to dispute the bill if your actual costs significantly exceed (by at least $400) those listed in the Good Faith Estimate. The dispute must be formally begun with the U.S. Department of Health and Human Services (HHS) within 120 calendar days of the date of the original bill. There is a $25 fee to use the dispute process. Initiating a dispute will not adversely affect the quality of mental health services provided to you.
• A Good Faith Estimate is not a contract, and does not obligate or require you to obtain any of the items or services listed in the estimate.
• Because mental health services are often on-going over a period of time, Dr. Hill will provide you with an estimate of recurring services lasting for 12 months. If services continue for more than 12 months, Dr. Hill will provide you with a new estimate for additional services beyond 12 months and discuss any changes between the initial estimate and the new one.
If you have questions or would like more information about the No Surprises Act, please visit www.cms.gov/nosurprises or call the No Surprises Help Desk at 1-800-985-3059.
Dr. Hill is proud to accept the following insurance plans:
• Medicaid (Health First Colorado/CCHA/CoAccess)*
• Child Health Plan Plus (CHP+)
• Kaiser Permanente (Beacon Health Options)
• Tricare (HNFS/MHN)
*Health First Colorado/Medicaid Members: There are no co-pays or out-of-pocket expenses for using Health First Colorado benefits for covered services. If you are not sure if you are covered by Health First Colorado, Dr. Hill can help you verify your benefits.
|Initial 20-minute phone consultation
|Initial 75-minute intake session
|$150 per 55-minute session
|$80 per 55-minute session
|Consultation/coaching with parents
|$150 per 55-minute session
|Phone consultation on client's behalf
|$12.50 per 5-minute interval
|$150 per 55-minute session (plus travel costs)
|$155 per 60-minute hour (plus travel costs)
|Phone calls with client/guardian
|No charge for phone calls lasting up to 10 minutes; $15 for each 5-minute interval thereafter
|Copies of records/paperwork
|1 copy of outcome paperwork (reports) is provided at the conclusion of the service at no charge;
Fees for additional copies and all other record requests include postage, time/labor (billed at $12.50 per 5-minute interval) and supplies/materials ($0.10 per single-sided page)
|Includes travel time to/from off-site locations (billed at $12.50 per 5-minute interval) and mileage to/from off-site locations (based on the IRS Standard Mileage Rates, currently $0.58/mile)
|$350 per 60-minute hour (plus travel costs)
(All rates and fees are subject to change.)
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