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Good faith estimates

YOUR RIGHTS AND PROTECTION AGAINST SURPRISE MEDICAL BILLS AND TO RECEIVE A GOOD FAITH ESTIMATE

The services you are receiving may not be covered by your health plan. You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network. When you get emergency care or get treated by an out-of-network provider at an in-network hospital, you are protected from surprise or balance billing. Balance Billing (sometimes called Surprise Billing) is an unexpected balance bill that can happen when you cannot control who is involved in your care, like in an emergency, or when you schedule a visit at an in-network facility but are treated by an out-of-network provider. “Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

You are protected from balance billing for emergency services and medicine. If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

You are protected from balance billing for anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. When you get services from an in-network hospital, certain providers there may be out-of-network. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. For all other services at in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees. Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service. Make sure to save a copy or picture of your Good Faith Estimate. Upon consenting to receive the services provided for the Good Faith Estimate, you may be billed for the difference between your health plan issuers out-of-network reimbursement and the provider’s charge for the services. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

When balance billing isn’t allowed, you also have the following protections:

  • You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
  • Your health plan generally must:
    • Cover emergency services without requiring you to get approval for services in advance (prior authorization).
    • Cover emergency services by out-of-network providers.
    • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
    • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed or that your rights have been violated, visit www.cms.gov/nosurprises for more information about your rights under federal law or call 1-800-985-3059. Visit https://insurance.ohio.gov/wps/portal/gov/odi/consumers/health/surprise-billing for more information about your rights under Ohio law.