The short answer
When a client is uninsured or choosing not to use insurance. Under the No Surprises Act, you must give a written Good Faith Estimate of expected charges when they schedule or ask. Clients using government programs like Medicare, Medicaid, or TRICARE aren't covered by this requirement.
Who needs a Good Faith Estimate?
Clients who are uninsured or self-pay, meaning they have coverage but choose not to use it for your services. The No Surprises Act requires providers to give these clients a written Good Faith Estimate (GFE) of expected charges. See CMS's provider requirements.
CMS's decision tree says people enrolled in federal health care programs, such as Medicare, Medicaid, or TRICARE, aren't eligible for this GFE.
When do you have to give it?
Per CMS's decision tree:
| Situation | Deadline |
|---|---|
| Client asks for an estimate | Within 3 business days of the request |
| Scheduled 3 to 9 business days ahead | Within 1 business day of scheduling |
| Scheduled 10 or more business days ahead | Within 3 business days of scheduling |
| Scheduled fewer than 3 business days ahead | Not required |
If the expected services change before the visit, send an updated estimate at least 1 business day before.
What about ongoing therapy?
For recurring services like counseling, CMS allows a single GFE covering the expected series of sessions, instead of one per visit. Include the expected number and frequency of sessions and the charge for each.
What goes in a GFE?
CMS publishes a sample Good Faith Estimate. It generally includes the client's name, a description of services, expected charges with service codes, your information, and a notice about the client's dispute rights.
What if the final bill is much higher?
Clients can use the patient-provider dispute resolution process if billed charges are substantially more than the estimate, under thresholds HHS sets. Keeping estimates realistic, and updating them when the plan changes, protects you.
How ValorWell handles this
ValorWell's clients are generally covered through CHAMPVA, VA Community Care, or the ValorWell Foundation, so ValorWell handles financial communication with clients through those pathways. If you keep a private practice with self-pay clients, the GFE rules apply to your own practice.
Important limits
- This page isn't legal advice. CMS guidance and state law can add requirements.
- Rules can change. Check CMS's No Surprises Act pages for current guidance.
- The GFE isn't a contract. Bill accurately for what you actually provide.