Cash Pay Disclosure & Good Faith Estimate Notice

1. Notice Regarding Insurance

Modulus Health Group is a cash-pay practice. We do not bill health insurance, Medicare, Medicaid, or any other third-party payor. You are responsible for paying the full cost of services provided by Modulus Health Group.

Payment is due at the time of enrollment or according to the payment terms in your Terms of Service. Annual membership fees are collected in full at the time of enrollment and upon each annual renewal.

2. HSA/FSA Eligibility and Out-of-Network Reimbursement

HSA/FSA Eligibility

Services provided by Modulus Health Group are delivered by licensed physicians and constitute medical care. As such, your membership fees and service charges may be eligible for reimbursement from your Health Savings Account (HSA) or Flexible Spending Account (FSA). Please consult your plan administrator to confirm eligibility.

Out-of-Network Reimbursement

Although we do not bill insurance on your behalf, you may be able to submit claims to your insurance company for potential out-of-network reimbursement. Please understand:

• Modulus Health Group makes no guarantee that your insurance will reimburse you
• Reimbursement policies vary by insurance plan and are determined solely by your insurer
• You are responsible for understanding your insurance benefits
• Upon request, we will provide you with a superbill containing the appropriate billing codes (CPT and ICD-10) that you may submit to your insurance company or HSA/FSA administrator

3. Your Rights Under the No Surprises Act — Good Faith Estimate

You have the right to receive a "Good Faith Estimate" explaining how much your medical care will cost.

Under the No Surprises Act, healthcare providers are required to give patients who do not have insurance or who are not using insurance an estimate of the expected bill for medical items and services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services, including related costs like medical tests, prescription drugs, equipment, and hospital fees.
• Your healthcare provider must give you a Good Faith Estimate in writing at least one (1) business day before your medical service or item. You can also ask for a Good Faith Estimate before you schedule an item or service.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.

A personalized Good Faith Estimate will be provided to you during the enrollment process, before payment is collected.

4. Modulus Health Group Services and Fees

The following is a summary of current Modulus Health Group fees. This information is provided to help you understand the cost of our Services and serves as a general Good Faith Estimate for each service tier. Your personalized Good Faith Estimate will be provided during enrollment.

Pricing is subject to change. Current pricing is always available at modulus.ai. You will be notified of any pricing changes prior to your membership renewal.

5. Additional Costs Not Included in Modulus Health Group Fees

• Laboratory tests — billed directly by the laboratory (e.g., Quest Diagnostics, Labcorp, specialty labs). Costs vary by test and laboratory. Your lab may bill your insurance if you provide your insurance information to them directly.
• Diagnostic imaging — billed directly by the imaging facility (MRI, CT, X-ray, ultrasound, etc.). Costs vary by type of study and facility.
• Prescription medications — billed directly by the pharmacy. Costs vary by medication; your pharmacy may bill your insurance or accept manufacturer coupons.
• Specialist consultations — billed directly by the specialist if you choose to see one in person following a referral from Modulus Health Group.
• Hospital or emergency services — billed directly by the facility. Modulus Health Group does not provide emergency care.

You are responsible for all costs associated with laboratory tests, imaging, prescriptions, and referrals ordered as part of your care with Modulus Health Group. We recommend contacting the third-party provider in advance to understand your expected costs.

6. Disputing a Bill

If you believe you have been billed more than $400 above your Good Faith Estimate for services provided by Modulus Health Group, you have the right to dispute the bill. You may contact us to discuss the charges, or you may initiate the federal dispute resolution process.

To start a dispute, visit www.cms.gov/nosurprises/consumers/resolve-payment-disputes or call 1-800-985-3059.

Please note that the Good Faith Estimate and dispute process apply only to charges from Modulus Health Group. Charges from third-party providers (laboratories, imaging facilities, pharmacies, specialists) are subject to those providers' own billing practices and dispute processes.

7. Contact Information

If you have questions about pricing, billing, or your Good Faith Estimate, please contact us: