How uninsured patients can get a good faith estimate

What is a good faith estimate?

A good faith estimate is a written price quote. It tells you what a doctor, clinic or hospital expects your care to cost. It comes from a federal law called the No Surprises Act.

The Centers for Medicare and Medicaid Services, or CMS, is the federal agency that runs Medicare. CMS says providers and facilities must give a good faith estimate to people without insurance. The same goes for people who choose not to use their insurance. CMS also says this applies in most cases, so it is worth asking.

The idea is that you should know the price before you agree to care, the same way you would for a car repair. This page is general information and not legal or medical advice.

Who gets a good faith estimate, and when?

You can get one if you are uninsured or if you have insurance but plan to pay on your own. According to CMS, you get an estimate when you schedule care at least three business days ahead, or when you ask for one. A business day is a normal working day, not a weekend or holiday.

The federal guidance sets two timing rules. If your care is scheduled at least three business days ahead, the estimate is due no later than one business day after scheduling. If your care is scheduled at least ten business days ahead, the estimate is due no later than three business days after you schedule. The same deadline applies if you ask about the price without scheduling anything.

You do not get an estimate during emergency care, and CMS says so directly. If you have an emergency, call 911 or go to the nearest ER. Our guide on the ER with no insurance explains what to do about the bill afterward.

What must be in the estimate

According to CMS guidance, a good faith estimate should include the items below.

• The estimate lists the items and services the provider or facility expects to give you.
• It includes codes for your diagnosis and for each service, which are numbers that billing offices use.
• It shows the expected charge for each item or service.
• It has a notice that says you can ask for an updated bill, try to negotiate the bill, or ask about financial assistance if the bill is higher.
• It explains how to dispute a bill that is at least $400 higher than the estimate.

Each estimate covers only one provider or facility. CMS advises asking for one from each provider and facility involved in your care. Care that was not expected is not included.

How do I ask for one?

1. Call the office or facility before the visit. You can say, "I do not have insurance and I will pay on my own, so can I get a good faith estimate?"
2. Tell them what care you expect, such as a procedure or a series of visits.
3. Ask who else will bill you, for example a surgeon, an anesthesia group or a lab, and ask for estimates from them too.
4. Ask that the estimate be sent in writing, by mail or email.
5. Keep the estimate in a safe place, because you will need it if you ever dispute the bill.

If the estimate seems high, you can ask whether a lower self-pay price is available. Our guide on asking for the cash price has a phone script. You can also read our guide on how to negotiate a medical bill.

A simple example of the $400 rule

Here is an example with made-up numbers, just to show how it works. Suppose a clinic's estimate says your care will cost $1,000, and then the clinic bills you $1,400. That is $400 more than the estimate, so you may be able to dispute it. If the bill had been $1,300, it would be $300 more, and the dispute process would not apply. You could still call the billing office and ask them to look at the difference.

The rule looks at each provider or facility on its own. If you had care from a surgeon and from a hospital, each has its own estimate and its own $400 test.

What if the bill is much higher than the estimate?

CMS says you may be able to dispute a bill that charges at least $400 more than the estimate for that provider or facility. This is called the patient-provider dispute resolution process. Here are the main points from CMS.

• You need a written good faith estimate to use this process.
• The $400 test is applied separately to each provider or facility.
• You must start the dispute within 120 calendar days of getting the first bill, and the notice has to be submitted online, faxed, or postmarked within that time.
• There may be a small fee to start, and it may change from year to year, so check the current amount with CMS.
• A neutral reviewer decides what you owe.

Before you file, call the billing office, show them the estimate and ask them to fix the bill. Many mistakes are fixed this way. Mark the 120-day date on a calendar the day the bill arrives. If you need more help, you can call the No Surprises Help Desk at 1-800-985-3059, which CMS lists as offering help in over 350 languages.

What if I cannot pay, even when the bill matches the estimate?

An estimate tells you the price, and it does not make the price lower. If the price is more than you can afford, ask the hospital about financial assistance. Nonprofit hospitals must have a policy, and our guide on hospital financial assistance shows how to apply. Our guide on medical bill help has more ideas.

If you want a doctor whose prices are clear from the start, you can search our directory of cash-pay doctors. Many direct primary care practices post their monthly fee, usually $50 to $200 a month.