Compliance with No Surprises Act:

• In accordance with the federal No Surprises Act (effective January 1, 2022), we provide uninsured and self-pay clients with a good faith estimate of costs for our services. This estimate is designed to help you anticipate potential costs and avoid surprise bills.

The current full rates for individual counseling, couples, and families  and psychotherapy services with a licensed provider (e.g. LPC, LCSW, LMFT, MA, MS) at Modern Intervention Strategies, LLC are listed below and outlined in the Practice Fee Schedule. 

Packaged Standard 60-min Session private pay rates:

• 10 sessions: Individual=$$2,040, couples= $2,820, families=$3,300
• 16 sessions: Individual=$3,800, couples =$4,452, families= $5,280
• 20 sessions: Individual=4,800, couples=$5,640, families= $6,600 

The current rate for individual counseling and psychotherapy services with Masters-level Interns at Modern Intervention Strategies, LLC is listed below and outlined in the Reduced Fee Financial Agreement. 

• Standard 50-min Session private pay – $75 

Other common items and services provided at Modern Intervention Strategies, LLC are listed below. Note that this list is not exhaustive and does not represent all services which a client may request or require.

• Cancellation/No-Shows – clients are responsible for the full session fee for missed appointments or would forfeit one of the sessions from the package. 

It is your right to determine your goals for treatment and how long you would like to remain in therapy unless you are pursuing mandatory treatment. You and your therapist will continually check in regarding your progress, to assess the appropriate frequency of your sessions, and to determine when you have met your goals and are ready to end therapy. The fees outlined are provided to support you in discussing with your therapist what you may owe if you agree to receive care at Modern Intervention Strategies, LLC. The total cost of services may be influenced by many factors:

• Your schedule and life circumstances
• Therapist availability
• Ongoing life challenges
• The nature of your specific presenting concerns/diagnosis (if applicable) and how you address them

Modern Intervention Strategies,  LLC is not currently in-network with any insurance plans. This means that Modern Intervention Strategies, LLC does not have an agreement with any insurance plans. Clients who are enrolled in an insurance plan and consent to receive services here acknowledge that they will be responsible for the full cost billed for any items or services received and understand that receiving services here may cost them more. Clients are encouraged to contact their health plan for support in finding an in-network provider, or if they intend to request reimbursement for out-of-network services or apply their payments toward their out-of-pocket limit; an insurer may agree to negotiate an arrangement with an out-of-network provider if there are no in-network providers available. You should not consent to receive services at Modern Intervention Strategies,  LLC if you did not have a choice of where to receive care. By consenting to receive services at Modern Intervention Strategies,  LLC, you understand that

• You are giving up your protections under the law.
• You may owe the full costs billed for items and services received.
• Your health insurance plan might not count any of the amount you pay towards your deductible and out- of-pocket limit, and may not reimburse you fully or at all for any out-of-pocket payments that you make. Contact your health plan for more information

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. The Good Faith Estimate does not include any unknown or unexpected costs or services that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.

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

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 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) 368-1019. 

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) 368-1019.

Modern intervention Strategies,  LLC
EIN 84-3267788