Good Faith Estimates: Your Right to Know the Price Before You Get Care

What does the No Surprises Act require from providers?

The No Surprises Act, which took effect January 1, 2022, requires health care providers and facilities — including physicians, hospitals, outpatient clinics, and telehealth services — to give uninsured or self-pay patients a GFE before any scheduled service 1Ref 1U.S. Centers for Medicare & Medicaid Services (2022).No Surprises Act: Good Faith Estimates and Consumer Rights.No Surprises Act requirements for good faith estimates including timing, scope, and the $400 dispute threshold for uninsured and self-pay patients; effective January 1, 2022.

The estimate must cover expected charges for the primary service and any items or services reasonably expected to be part of the same episode of care — for example, anesthesia for a planned surgery or pathology review of a removed specimen. Timing requirements:

• At least one business day before your appointment if you schedule three or more days in advance
• At least three business days before if you schedule 10 or more days out
• You may also request one at any time, even before you schedule

No specialties are exempt — it applies to any provider or facility that schedules care in advance 1Ref 1U.S. Centers for Medicare & Medicaid Services (2022).No Surprises Act: Good Faith Estimates and Consumer Rights.No Surprises Act requirements for good faith estimates including timing, scope, and the $400 dispute threshold for uninsured and self-pay patients; effective January 1, 2022. The law covers all types of providers: physicians, therapists, hospitals, outpatient surgical centers, and telehealth providers.

If you have insurance, providers are not always required to issue a GFE to you directly, but asking is still worthwhile — many will provide one, and it helps you anticipate your out-of-pocket share before you receive an Explanation of Benefits.

What does the estimate include — and what is missing?

A complete GFE will list each service with its billing code and expected charge, and identify which provider or facility is responsible for each item.

What a GFE typically does not include:

• The portion your insurance will cover (that depends on your plan's negotiated rates, deductible, and benefits — your Explanation of Benefits is the place to see that)
• Emergency services that cannot be anticipated in advance
• Services from out-of-network providers you have not been told about

If you have insurance, your insurer must also provide an Advanced Explanation of Benefits for many scheduled services — this is separate from the GFE but serves a similar transparency function.

How do you request a good faith estimate?

Simply ask when you call to schedule any non-emergency service: "I would like a good faith estimate before my appointment."

For uninsured and self-pay patients, the provider is legally required to provide it within the deadlines described above 1Ref 1U.S. Centers for Medicare & Medicaid Services (2022).No Surprises Act: Good Faith Estimates and Consumer Rights.No Surprises Act requirements for good faith estimates including timing, scope, and the $400 dispute threshold for uninsured and self-pay patients; effective January 1, 2022. For insured patients, it is still worth requesting. Get the estimate in writing — paper or electronic — and keep a copy alongside your eventual bill.

When reviewing your GFE, check: - That every expected service is listed with its specific billing code - That the provider performing each service is identified - Whether any co-providers (like an anesthesiologist or pathologist) are listed separately - Whether the estimate notes any conditions under which charges might differ

At Gale, you can ask before booking what to expect in terms of charges for your visit type.

What can you do if your bill is higher than the estimate?

If you are uninsured or self-pay and your final bill is more than $400 above what the GFE quoted for the same service, you have the right to dispute it through the Patient-Provider Dispute Resolution process established by the No Surprises Act 1Ref 1U.S. Centers for Medicare & Medicaid Services (2022).No Surprises Act: Good Faith Estimates and Consumer Rights.No Surprises Act requirements for good faith estimates including timing, scope, and the $400 dispute threshold for uninsured and self-pay patients; effective January 1, 2022. There is a small administrative fee to initiate the process. CMS provides a help desk at 1-800-985-3059 and an online portal for filing complaints and initiating disputes.

When preparing a dispute, gather: - A copy of the original GFE - The final itemized bill - Any Explanation of Benefits (EOB) from your insurer - A written record of phone calls, including dates, representative names, and reference numbers

If you have insurance, the dispute pathway is different — start with your insurer's member services line, then your state's insurance commissioner if needed. Your state commissioner's office can investigate whether a claim was processed correctly and whether your plan's billing practices comply with state law.

What is an Advanced Explanation of Benefits, and how is it different?

If you have insurance and receive a scheduled service, your insurer — not just the provider — must also send you an Advanced Explanation of Benefits (AEOB) for many types of care. The AEOB estimates your expected cost-sharing — your deductible, copay, coinsurance, and what insurance will pay — based on your current plan details and deductible status.

The GFE from the provider and the AEOB from your insurer work together: the GFE shows what the provider expects to charge; the AEOB shows what you are likely to owe after insurance processes the claim. Together they give you the most complete picture of upcoming costs.

Insured patients receiving scheduled services from Marketplace plans are entitled to advance cost transparency from their insurer, in addition to the provider's GFE 2Ref 2HealthCare.gov / U.S. Centers for Medicare & Medicaid Services (2024).Find out what Marketplace health insurance plans cover.Marketplace plans must cover mental health and other essential health benefits; insurers must provide Explanations of Benefits and advance cost transparency for covered services. If you disagree with a cost estimate or find that a service is not covered as expected, you can contact your insurer's member services line or your state insurance commissioner's office for assistance.