Good Faith Estimate (GFE) Policy

UNDERSTANDING THE NO SURPRISES ACT AND GOOD FAITH ESTIMATE

The No Surprises Act is a federal law that protects you from unexpected medical bills, especially those related to emergency care or services provided by out-of-network providers at in-network facilities. The law is designed to ensure you are only responsible for your standard in-network costs in certain situations, giving you greater peace of mind and financial protection.

An important part of this law is the Good Faith Estimate (GFE). You have the right to receive a Good Faith Estimate explaining how much your medical care will cost. A Good Faith Estimate is a written document that health care providers and facilities must give to clients who are uninsured or who choose not to use their insurance (self-pay/private pay). The GFE provides an estimate of the total expected charges for non-emergency services, including:

• The provider’s fees for each service, such as individual therapy sessions, evaluations, assessments, or diagnostic services provided by Rejoice in the Rain Counseling PLLC.

• Any other expected charges, such as facility fees or related services (if applicable).

• The period these estimates cover.

This helps you understand and plan for your health care expenses in advance.

YOUR RIGHTS UNDER THE NO SURPRISES ACT

• Protection from Balance Billing: In certain situations, such as emergency services or when you receive care from an out-of-network provider at an in-network facility, you cannot be billed for more than your in-network cost-sharing amount.

• Right to a Good Faith Estimate: If you are uninsured or not using insurance, you can request a Good Faith Estimate for any non-emergency services before you schedule or receive care.

• Right to Dispute Bills: If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill.

HOW TO REQUEST A GOOD FAITH ESTIMATE

• You can request a Good Faith Estimate from Rejoice in the Rain Counseling PLLC at any time before you schedule a service, or at least one business day before your appointment. We will provide your estimate in writing within 24 business hours of your request (excluding holidays or planned time off). You may also request a paper copy if you prefer.

• For ongoing therapy, a new Good Faith Estimate will be provided at least every three months, or sooner if your treatment plan or fees change.

IMPORTANT INFORMATION ABOUT GOOD FAITH ESTIMATES (GFE)

• This is an estimate, not a bill. The actual charges may differ depending on the services you receive.

• The GFE is based on information known at the time it was created and is subject to change.

• This GFE is valid for 30 days from the date of issue. If your treatment plan changes significantly, a new Good Faith Estimate will be provided.

• This GFE is not a guarantee that your insurance will cover the services listed. Please contact your insurance provider to confirm your benefits and coverage.

• If you are using insurance, it is your responsibility to understand your insurance coverage, network status, and benefits.

• Rejoice in the Rain Counseling PLLC does not offer bundled or package services; each service is billed separately.

• This GFE does not include costs for any unforeseen services or items that may become necessary during your treatment.

• If you receive a bill that is at least $400 more than your GFE, you have the right to dispute the bill.

DISPUTE RESOLUTION PROCESS

If you receive a bill that is at least $400 more than your Good Faith Estimate, please contact Rejoice in the Rain Counseling PLLC directly as soon as possible. We are committed to resolving any billing concerns with you promptly and directly. If we are unable to resolve your concerns, you have the right to initiate a dispute resolution process with the U.S. Department of Health and Human Services (HHS) within 120 days of receiving the bill.

• To learn more about the dispute process or to start a dispute, visit: https://www.cms.gov/nosurprises/consumers or call 1-800-985-3059.

STATE-SPECIFIC INFORMATION

If there are any additional requirements for Good Faith Estimates under Texas or Vermont law, those will be provided to you as required. If you have questions about your rights in your state, about the your rights under the No Surprises Act, or to request a Good Faith Estimate, please use the contact information listed at the bottom of this policy.

• To learn more about your rights under the No Surprises Act, visit: https://www.cms.gov/nosurprises