Who needs a Good Faith Estimate
The rule turns on how the client pays, not on whether they have insurance. That catches a lot of practices out.
Reviewed August 2026 · Not legal advice
Since 1 January 2022, the No Surprises Act has required health care providers to hand certain clients a written estimate of what their care will cost before it happens. Therapists are providers for this purpose. A solo private practice with no billing staff is covered exactly as a hospital is.
The two groups who are owed one
The regulation uses the term uninsured (or self-pay) individual, and it covers two distinct situations:
- Someone with no health coverage that would pay for the service — no group plan, no individual policy, no federal program.
- Someone who does have such coverage but is not asking you to bill it.
An individual who has benefits for an item or service under a group health plan or health insurance coverage, but who does not seek to have a claim for such item or service submitted to such plan or coverage.
That second group is the one that surprises people. Insurance in the client’s wallet does not remove your obligation. What matters is whether a claim is going to your plan for that service. In a practice that sees a mix of insured and private-pay clients, the private-pay ones are owed estimates regardless of their coverage status.
Because that case comes up constantly in therapy — sliding scale, out-of-network work, superbills, clients protecting their privacy — it has its own page: insured clients who pay out of pocket.
What sets the obligation running
Two events trigger it. The client schedules an appointment, or the client asks what care will cost. Either one starts a clock measured in business days.
A general conversation about your fees does not. If someone emails to ask what you charge and nothing is booked, you have answered a question, not triggered the rule. The moment they ask for an estimate of their expected costs, or put a session in your calendar, you are on the clock.
The deadlines are shorter than most practices assume, and they run from the day of scheduling rather than the day of the session. That distinction is covered in when a Good Faith Estimate is due.
Clients you bill through insurance
If you are submitting a claim to the client’s plan for the session, this particular requirement does not apply to them. Those clients are covered by different parts of the No Surprises Act — the balance-billing protections and, eventually, the advanced explanation of benefits, which requires a provider-to-plan exchange that has not yet been implemented.
A practice that bills insurance for some clients and not others therefore has a split obligation. The practical approach most therapists land on is to make the estimate part of intake for anyone not being billed to a plan, rather than trying to remember case by case.
What happens if you don’t
Enforcement sits with the states in the first instance, with the federal government stepping in where a state does not substantially enforce. Civil monetary penalties run up to $10,000 per violation. Penalties can be waived where a provider did not knowingly violate the rule, could not reasonably have known, and corrects the error — but the more consequential exposure for a small practice is usually the dispute process rather than a penalty, since a client whose bill exceeds their estimate by $400 or more can challenge it directly.
EstimateHarbor is not a law firm and this page is not legal advice. It summarises the federal rule at 45 CFR § 149.610 as we read it, for general information. Your state may impose additional requirements, and how the rule applies to your practice is a question for your own counsel or professional association.