Good Faith Estimates for DPC Patients (No Surprises Act Rules for Self-Pay Care)

Does a DPC Practice Need a Good Faith Estimate?

Most likely yes. The No Surprises Act requires providers to give a written good faith estimate to uninsured and self-pay patients when they schedule care or ask about cost, and a DPC member with private or employer coverage who does not send a claim to insurance fits the federal definition of self-pay. CMS says people enrolled in a federal health care program such as Medicare, Medicaid or TRICARE are not eligible for one, even if they do not plan to use that coverage. CMS has never issued an exemption for direct primary care, so the cautious approach is to hand every self-pay member a written estimate at enrollment that covers the membership for up to 12 months, and a fresh estimate whenever a patient schedules or asks about something you bill outside the membership.

DPC is already built on posted, predictable prices, so the estimate itself is usually short. The work is in the details the rule asks for and in keeping estimates current when prices change. This guide is a summary of federal rules, not legal advice.

What the No Surprises Act Requires for Self-Pay Patients

The requirement comes from section 2799B-6 of the Public Health Service Act, added by the No Surprises Act, and is implemented in 45 CFR 149.610. It has applied since January 1, 2022, and it covers health care providers and facilities of every size, not only hospitals.

The rule defines an uninsured (or self-pay) individual in two ways. The first is someone with no benefits for the item or service under a group health plan, individual or group insurance, a federal health care program or FEHB coverage. The second is someone who has benefits under a group health plan, individual or group insurance or FEHB coverage but does not seek to have a claim submitted for the item or service.

That second part is why DPC is in scope. A member with an employer plan who pays you directly and never files a claim for your services is, for those services, a self-pay patient. The second part of the definition lists private coverage and FEHB but not federal health care programs, and CMS's decision tree says people enrolled in a federal health care program such as Medicare, Medicaid or TRICARE are not eligible for a good faith estimate, even if they do not plan to use that coverage, because those programs have other surprise billing protections. So the estimate and dispute steps in this guide apply to uninsured patients and to members with private or employer coverage who do not file a claim, not to your Medicare, Medicaid or TRICARE patients.

The provider who schedules the main service, called the convening provider, also has duties before anyone asks. Under the rule you must:

• Ask whether the patient has coverage and whether they plan to file a claim for the service.
• Tell every uninsured or self-pay patient that a good faith estimate is available, orally when scheduling or when cost comes up, and in writing.
• Post that notice prominently on your website (easily searchable from a public search engine), in the office and where scheduling happens, in accessible formats and in the languages your patients speak.
• Keep each estimate as part of the patient's medical record and give a copy of any estimate from the last 6 years when the patient asks.

Is a DPC Membership an "Item or Service" That Needs an Estimate?

This is the honest gray area. The regulation and CMS's FAQs talk about scheduled items and services and recurring services, but none of the CMS guidance we reviewed mentions membership fees or direct primary care by name.

The clearest public statement comes from the American Academy of Family Physicians. In a December 3, 2021 letter to CMS, the AAFP wrote that it interprets the good faith estimate requirement to apply to DPC practices, based on the definition of a self-pay patient. It called the requirement unnecessary and burdensome for practices that already post prices and contract for a flat fee, and it asked HHS to exempt DPC when everything reasonably expected is already included in the flat fee, or when a patient sends extra services to insurance.

HHS has not adopted that exemption. The rule still has no DPC carve-out, and the CMS FAQ series on self-pay estimates does not address memberships. So the careful reading is that the main professional body for family physicians believes the rule applies, the agency has not said otherwise, and a practice that issues estimates is on firmer ground than one that does not.

There is one related piece of CMS guidance worth knowing about. In FAQ Part 4 (December 27, 2022), HHS allowed an abbreviated good faith estimate for providers that know in advance they will not bill the patient at all. It is tempting to read that onto member visits with no per-visit charge. HHS, though, "strongly recommends that only providers and facilities that furnish all items or services free of charge use an abbreviated GFE." Because members pay a membership fee, a full estimate that lists the fee is the more conservative choice.

When You Have to Give It (the 1 and 3 Business Day Rule)

Timing depends on how far ahead care is scheduled, and the clock runs in business days. Under 45 CFR 149.610(b)(1)(vi):

• Scheduled at least 3 business days ahead. The estimate is due no later than 1 business day after scheduling.
• Scheduled at least 10 business days ahead. The estimate is due no later than 3 business days after scheduling.
• Requested by the patient. The estimate is due no later than 3 business days after the request, whether or not anything is scheduled.

Same-day and next-day visits, which are a big part of DPC, usually fall under the 3 business day threshold, so the scheduling deadline does not kick in for them. That is one more reason to give a recurring estimate at enrollment. It puts the membership price in writing before the first visit, and it already exists if a member later asks for one.

If something changes, the rule asks for a new estimate. When the scope, providers or dates on an estimate change, the convening provider issues a new one, and if the change happens close to the visit, the new estimate is due no later than 1 business day before the scheduled service. An estimate given on request must also be replaced with a new one once the requested service is actually scheduled.

The 12-Month Rule for Recurring Services

The provision that matters most for memberships is the recurring services rule. Under 45 CFR 149.610(b)(1)(x), a convening provider may issue a single good faith estimate for recurring primary items or services if two conditions are met. The estimate must describe the expected scope of the recurring services in a clear way, such as timeframes, frequency and the total number of recurrences, and its scope cannot exceed 12 months.

A monthly membership maps naturally onto that structure. An estimate that lists the monthly fee, the number of months covered and the total for the period does the job, and it should be reissued at least every 12 months. Renewal season is a sensible time to do it, and so is any price increase.

If you are reviewing your fee for 2027, our guide on how much to charge for DPC membership covers pricing benchmarks, and a fee change is a good trigger to send every self-pay member an updated estimate.

What a Good Faith Estimate Must Include

The content list is in 45 CFR 149.610(c). It must be in writing, on paper or electronically as the patient prefers, and it must state that it is not a contract, so keep it as its own document rather than folding it into your membership agreement. The required elements are:

1. Patient name and date of birth.
2. A plain-language description of the primary item or service and, if scheduled, the date.
3. An itemized list of items and services reasonably expected for that period of care, grouped by provider or facility.
4. Applicable diagnosis codes, expected service codes and expected charges for each listed item, reflecting any discounts.
5. The name, NPI and Tax Identification Number of each provider or facility, and the state and office location where care is expected.
6. A list of items or services expected to need separate scheduling, with the required disclaimer above it.
7. A disclaimer that there may be other recommended items or services that must be scheduled or requested separately and are not on the estimate.
8. A disclaimer about the patient's right to dispute a bill that is substantially higher than the estimate, how to find information on starting the process, and that starting it will not affect the quality of care.
9. A disclaimer that the estimate is not a contract and does not require the patient to get care from any provider listed.

CMS publishes standard notice and estimate templates on its provider resources page, and building from those is easier than writing your own disclaimers. The rule also protects providers who act in good faith and with reasonable diligence, so an honest error or omission is not a violation as long as you correct it as soon as practicable.

The Convening Provider and Co-Provider Rules (Still Under Enforcement Discretion)

On paper, a good faith estimate must also include expected charges from co-providers and co-facilities, meaning other providers who will furnish care in conjunction with yours, such as an outside lab or imaging center billing the patient directly. The convening provider would collect that information and the co-providers would send it within 1 business day.

That part has never been enforced. HHS applied enforcement discretion for 2022, then in FAQ Part 3 (December 2, 2022) extended it "pending future rulemaking" for estimates that leave out co-provider and co-facility charges. No rule ending that discretion had been published as of October 29, 2026.

For a DPC practice, the practical line is between what you bill and what someone else bills. Labs you draw and bill at your negotiated price, medications you dispense and procedures you perform belong on your estimate. A send-out lab or imaging center that bills the patient directly can be left off under the current enforcement discretion, though a patient can always ask that provider for its own estimate.

Requirement, Rule and What It Means for a DPC

The 400-Dollar Dispute Threshold (Patient-Provider Dispute Resolution)

The good faith estimate is backed by a federal dispute process for self-pay patients, set out in 45 CFR 149.620. A patient can start patient-provider dispute resolution if one provider's total billed charges are substantially in excess of that provider's total expected charges on the estimate. The regulation defines "substantially in excess" as at least 400 dollars more than the expected charges.

According to CMS's consumer page on disputing a bill, the patient must start within 120 calendar days of the initial bill and pay a non-refundable administrative fee of 25 dollars.

For most DPC practices the risk is small, because membership pricing is fixed and posted. Where it shows up is in add-ons, such as several procedures or a large medication order that was never on an estimate.

A Practical DPC Good Faith Estimate Template

Here is what a DPC estimate could list, built around the content rules above. Use bracketed fields for your own numbers and have your attorney review the final version.

Header details. Patient name and date of birth, practice name, clinician NPI, practice TIN and the office address where care is provided.

Primary service. "Direct primary care membership for [month, year] through [month, year], [number] months, billed [monthly or annually]." Describe what the membership includes in plain words, matching your membership agreement.

Itemized expected charges.

• Monthly membership fee, [amount] per month for [number] months, with the total for the period.
• One-time enrollment or registration fee, if you charge one.
• Separately sold items you expect to provide, such as in-office labs at your listed price or dispensed medications at your listed price, with service codes where they apply.
• Any family or household discounts reflected in the charges, since the rule asks for prices after discounts.

There is no standard CPT code for a DPC membership, so a clear plain-language description is the most useful thing you can give the patient, and codes can go on the separately billed items where you know them. Ask your advisor how to handle the code fields for your setup.

Separately scheduled items. List things you expect to recommend later that will get their own estimate, such as a procedure or a send-out lab panel, under the required disclaimer.

Required disclaimers. The dispute rights disclaimer, the "not a contract" disclaimer and the "additional items may be recommended" disclaimer. The CMS template wording is the safest starting point.

The separately sold items deserve extra care in 2027. Under the One Big Beautiful Bill Act, a DPC membership leaves its members free to keep contributing to an HSA only if it stays within the monthly fee cap and leaves out certain services, which pushes many practices to sell medications and some labs outside the membership. Our guide to DPC HSA rules for 2027 explains the cap and the excluded services, and dispensing medications and labs in a DPC covers how practices price and sell those items. Whatever you sell separately should show up on the patient's estimate when you can reasonably expect to provide it.

Common Situations in a DPC Practice

A member schedules a procedure a week out. If it carries a separate charge and is scheduled at least 3 business days ahead, send an estimate within 1 business day. If it is included in the membership at no extra charge, the membership estimate should already describe it.

A prospective patient calls asking about price. That counts as a request, so a written estimate is due within 3 business days, even if they have not signed up.

You raise your fee. Issue updated estimates before the new price takes effect, and use the change as the start of a new 12-month period.

An employer pays the membership. The rule is written around the patient as the one paying, and CMS has not addressed employer-paid DPC memberships. If the member pays for separately sold items themselves, those items still call for an estimate. Ask your attorney about the membership line itself. Our guide to selling DPC to employers covers how those contracts usually work.

What Changed in 2026, and What to Watch for 2027

The self-pay rules have not changed. The current text of 45 CFR 149.610 is the same requirement providers have followed since 2022, and in a June 16, 2026 Federal Register notice CMS sought to reinstate the related paperwork collection for good faith estimates and dispute resolution "without change."

What may change is the rest of the No Surprises Act price disclosure framework. The federal regulatory agenda lists a proposed rule on advanced explanations of benefits (RIN 0938-AU98) with a target date of September 2026, and HFMA reported in October 2025 that congressional pressure made rules on estimates for insured patients likely in 2026. As of October 29, 2026, the Federal Register showed no such proposed rule. That rulemaking could also settle the co-provider question, so it is worth watching through 2027. State law is the other thing to watch, and our direct primary care laws by state guide is a good place to check yours.

Making Estimates Part of the Routine

Good faith estimates are easy to get right once and hard to keep right, because the moments that trigger them happen in different tools. Enrollment lives in your billing platform, scheduling in your calendar and the record in the EHR, and when those tools do not talk to each other, the estimate that should follow a scheduled procedure or a fee change is the one that slips.

Tabflows is a dedicated tech team that connects the tools a clinic already uses, like the EHR, membership billing and patient messaging, so steps like these get done. When a member schedules something billed separately or renews, sending and filing the estimate can show up as a task with the patient's context in one place.

If you are still planning your practice, the 2027 guide to starting a DPC puts estimates alongside the other compliance steps, and our roundup of DPC membership billing software for 2027 can help you pick a billing tool that makes recurring estimates easier to track.