Good Faith Estimate: How to Get a Price Before Care and Dispute a Bill That Beats It

Who this applies to

Uninsured patients, and insured patients who choose not to use their coverage for a particular service, which the rules call self-pay. If you are using insurance, the estimate rules work differently and your protection comes mainly from the surprise billing rules and your plan’s own estimate tools.

It applies to scheduled care. If care is scheduled at least three business days out, the estimate is owed automatically. If you ask for one, the provider owes you one whether or not anything is scheduled.

It does not apply to emergency care, by definition, because nothing was scheduled. That is what New York’s financial assistance caps and the emergency care rules are for.

What to say

To scheduling, or to the billing office, before the appointment:

“I am uninsured and paying out of pocket. Under the No Surprises Act I am requesting a good faith estimate in writing for this care, including every provider expected to bill me: the facility, the physician, anesthesia, pathology, radiology and any labs. Please send it to me before the appointment.”

The second half of that sentence is the useful part. An estimate covering only the facility charge, when three other entities will send bills, is technically an estimate and practically useless. Naming the categories forces a complete one.

What a complete estimate contains

Keep it. The whole dispute mechanism depends on being able to put the estimate next to the bill.

The $400 rule

If the final bill from a provider is $400 or more above what that provider’s good faith estimate said, you may start the federal patient-provider dispute resolution process. An independent third party reviews it and determines the amount you should pay.

The mechanics worth knowing:

The clock is 120 calendar days from the date you received the bill that exceeds the estimate. Miss it and this route closes.

There is an administrative fee, set at $25 when the process launched. It is refundable in defined circumstances.

Collection must stop. While the dispute is pending, the provider or facility may not pursue collection against you for the disputed amount, and may not move it toward a credit report or an agency.

It is per provider. The $400 comparison is between one provider’s estimate and that same provider’s bill, not against a combined total.

How it fits with New York’s own protections

Federal rules give you a price in advance and a way to contest a bill that ignores it. New York gives you a ceiling regardless of what any estimate said, and the state rules are frequently the stronger of the two for a hospital bill.

At or below 200% of the federal poverty level, a New York hospital may not charge an uninsured patient out-of-pocket costs for medically necessary care. Between 201% and 300% the charge is capped at 10% of the Medicaid rate, and between 301% and 400% at 20%. No hospital may sue a patient with income under 400%, and no asset test applies.

So the order of operations for an uninsured patient facing a large hospital bill is: apply for financial assistance first, because it may erase most of the balance, and use the estimate dispute for what survives or for bills from providers the state law does not bind, such as independent physician groups.

Before a scheduled procedure, three requests

The good faith estimate, complete, naming every billing entity.

The hospital’s written financial assistance policy and the state’s uniform application. The state rules are a floor, and many hospitals go beyond them.

The machine-readable price file, or at least the cash price for the specific service. Hospitals must publish their standard and negotiated charges, and for a planned procedure that file is the only public place the real numbers live. How to use it.

Doing all three takes one phone call and one email, and it is the difference between a number you were handed and a number you can check.