Good Faith Estimates and the No Surprises Act

What the No Surprises Act is and what it covers

The No Surprises Act took effect on January 1, 2022. Two of its parts matter most to patients. One generally protects people with most private health plans from certain surprise bills. The other gives people who are uninsured, or who choose not to use their insurance, a good faith estimate of expected charges for scheduled care. This guide covers both in general terms. It is not legal or medical advice, and details can vary with a person's situation and plan.

Protection from surprise out-of-network bills

A surprise bill usually arises when care comes from a provider or facility outside a plan's network that the patient did not choose. For people with most private health plans, the law generally protects against surprise bills in two situations:

• Emergency services, including at out-of-network facilities.
• Certain non-emergency services from out-of-network providers at in-network hospitals and ambulatory surgical centers.

In these cases, cost sharing is generally limited to in-network levels. Ground ambulance services are not covered by these protections, so a ground ambulance bill may be handled differently. This site does not advise on where to seek care. In a medical emergency, call 911 or go to the nearest emergency room.

Hospitals and physicians often bill separately, so a single visit can produce several bills. Our guide on facility fees versus professional fees explains why, and the guide to reading an itemized hospital bill can help sort out who billed what.

The good faith estimate for uninsured and self-pay patients

People who are uninsured, or who choose not to use their insurance (self-pay), can get a good faith estimate of expected charges for scheduled items and services. Providers must give one when a service is scheduled at least 3 business days ahead, or when a patient asks for one.

Some people ask for an estimate before committing to a provider, as a way to compare. Others ask at booking. Either way, a written estimate that lists the included services and codes can be easier to check later. Our guide on how to ask for the self-pay price offers sample wording for that conversation.

If the final bill is much higher than the estimate

An estimate is meant to set expectations, and the law includes a way to respond when a bill comes in far above it. If the final bill from a provider or facility is at least $400 more than its good faith estimate, the patient may be able to use the patient-provider dispute resolution process. That process generally must be started within 120 calendar days of the bill date.

Some people keep the estimate, the itemized bill and the bill date together so the dates are easy to check. CMS also runs a No Surprises help desk for questions about the process. For other routes, see our guide on negotiating a hospital bill.

How a hospital price list relates to an estimate

A price list and a good faith estimate are different things. The CMS Hospital Price Transparency rule (45 CFR Part 180) has applied since January 1, 2021. It requires each U.S. hospital to post a machine-readable file of its standard charges for all items and services. Those standard charges include:

• The gross charge
• The discounted cash price
• Payer-specific negotiated charges
• The de-identified minimum and maximum negotiated charges

The rule also requires a consumer-friendly display of 300 shoppable services (70 specified by CMS and the rest selected by the hospital), or an online price estimator tool instead. CMS describes a shoppable service as one that a patient can schedule in advance. CMS can enforce the rule with warning notices, corrective action plans and civil monetary penalties.

A price list is general and published for everyone, while a good faith estimate is prepared for a specific scheduled service. A list can show ranges and let people compare hospitals before asking for an estimate, which then reflects the services expected for that patient. To learn about the files themselves, see how to use hospital price transparency files and what shoppable services are.

What the prices on Clear Hospital Costs show

Clear Hospital Costs publishes hospital prices for Texas and Florida, refreshed from the hospitals' own files twice a week. Pages show gross charges, cash prices and insurer negotiated rates by hospital. Insurer rates can include Medicare Advantage and Medicaid managed care plans, and clear data errors are left out as described on our methodology page.

These are hospital facility charges taken from the hospitals' files, not total costs. Physicians such as surgeons, radiologists and anesthesiologists usually bill a separate professional fee, so the full price of a visit can be higher than what a hospital page shows. Some people use pages like MRI cost in Houston as a starting point, then ask the hospital and the physician practices for a written estimate. These prices are not a good faith estimate and do not replace one.

Related help and terms worth knowing

Hospital assistance may be an option for some patients. Nonprofit (tax-exempt) hospitals must meet IRS section 501(r) requirements, including a written financial assistance policy that is widely publicized. They must also limit what eligible patients are charged for emergency and other medically necessary care to no more than the amounts generally billed to insured patients. Each hospital sets its own eligibility rules, and many other hospitals also offer assistance, with terms that vary. See our guide to hospital financial assistance.

Estimates and bills often use codes. CPT codes are five-character codes maintained by the American Medical Association, and our guide on CPT codes explains how they appear on bills and price files. For background on where list prices come from, read what a chargemaster is.