A good faith estimate is a written estimate of expected charges that a provider or facility must give an uninsured or self-pay patient before scheduled care. The right comes from the federal No Surprises Act, and you do not have to explain why you want one. Self-pay means you have insurance but choose not to use it for a particular service.
Two triggers make it owed. If care is scheduled at least three business days out, the estimate is owed automatically; if you ask for one, it is owed whether or not anything is scheduled. It must cover every charge reasonably expected for that care: the facility, the physician, anesthesia, labs and imaging. The surprise in a medical bill is rarely the main service, which is why an estimate that prices the facility alone is incomplete.
The part people get wrong is what the estimate guarantees. A bill can still come in higher; the estimate gives you a trigger. If one provider’s bill is $400 or more above that same provider’s estimate, you can start the federal patient-provider dispute resolution process, and an independent third party decides what you should pay. You have 120 calendar days from receiving the bill, the fee to file has been set at $25, and while the dispute is pending the provider may not pursue collection of the disputed amount.
You get it from the scheduling or billing office before the appointment. Check that it names you, the service and its date, gives a charge for each item, lists by name every provider expected to bill you, and states that it is an estimate, along with your right to dispute a bill that exceeds it. Keep it: any later dispute starts by laying it next to the bill. Two other price documents get confused with it:
| Document | What it gives you | Where it stops |
|---|---|---|
| Good faith estimate | Expected charges for your scheduled care, from every provider expected to bill you, in writing | Uninsured and self-pay patients only, and never emergency care |
| Price quoted at the desk | The self-pay price for a visit | The quoted visit price often leaves out labs, imaging or a procedure |
| Hospital price file | Gross charges, cash prices and insurer-negotiated rates, public and free | Hospital charges only, no physician fees, and not a promise about your case |
In New York: the estimate is federal law, the hospital financial assistance law is state law, and the two stack. At or below 200% of the federal poverty level, a New York hospital may not charge an uninsured patient out of pocket for medically necessary care, whatever the estimate said. From 201% to 300% the charge is capped at 10% of the Medicaid rate, and from 301% to 400% at 20% of the Medicaid rate; no hospital may sue a patient with income under 400%, and there is no asset test. That sets the order for an uninsured New Yorker facing a large hospital bill: 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. Emergency care never gets an estimate, because nothing was scheduled; there the state caps still apply, and an uninsured patient can take an emergency bill they believe is excessive to independent dispute resolution through the Department of Financial Services. If you are using insurance, your protection comes mainly from the surprise billing rules and your plan’s own estimate tools.
What to do:
- Ask in writing before the appointment, naming every category: facility, physician, anesthesia, pathology, radiology and labs.
- Do not pay a bill that runs $400 or more over the estimate. Dispute it within the 120 days.
- Ask the hospital for its written financial assistance policy and the state’s uniform application at the same time.
- For a planned procedure, get the CPT code and check the cash price in the hospital’s price file.
Also called: GFE, advance cost estimate. Full guide: Good faith estimates and what to do when the bill is bigger. Reference: Good faith estimate on Wikipedia — general definition, not New York specifics.
More in Glossary of health coverage and billing terms
- Allowed amount — The number a plan treats as the price of a service, which is almost never the number on the bill and is what your percentage share is actually taken from.
- Tax household — The group whose income is counted together for coverage eligibility, decided by who files a tax return with whom rather than by who lives in the apartment.
- Qualified health plan — A plan certified for sale on a health insurance marketplace, which guarantees a floor of benefits and protections and tells you nothing about the network.
This page explains how the system works. It is not medical advice. More.