Beginning January 1, 2022, facilities must provide a good faith estimate of expected charges to uninsured consumers, or to insured consumers If they don’t plan to have their health plan help cover the costs (self-paying individuals). The good-faith estimate must be provided after a patient has scheduled a surgery, or upon their request. It should include expected charges for the primary item or service they’re getting, and any other items or services that are provided as part of the same scheduled experience.
Balance Billing: When a facility bills the patient for the difference between the provider's charge and the allowed amount.
Cost Sharing Amount: The patient cost sharing amounts include co-insurance, co-pay and deductible.
Estimate: The estimate should include the cost of the surgery, any labs or tests, and the anesthesia that might be used during the operation. Items or services related to the surgery that might be scheduled separately, like pre-surgery appointments or physical therapy in the weeks after the surgery, won’t be included in the good-faith estimate.
Non-Participating: A non-participating provider has not entered into an agreement to accept assignment on all Medicare claims.
Out of Network: Out-of-network providers have not agreed to the discounted rates.
Qualifying Payment Amount (QPA): The plan's median contracted rate — the middle amount in an ascending or descending list of contracted rates, adjusted for market consumer price index in urban areas.
Surprise Medical Bill: A surprise medical bill is an unexpected bill from a facility that occurs when a is a nonparticipating facility is not in network with the individual health plan.
All uninsured patients will be provided with a copy of the Patient Rights and Protections against Surprise Medical Bills Facility Notice, and a good faith estimate of costs for their surgery including anesthesia, and transportation to a hospital in the event of an emergency.
The good-faith estimate will be explained to the patient over the phone or in-person if the patient requests it and followed with a paper or electronic estimate.