Good Faith Estimates
Your Rights & Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
What Is “Balance Billing” Or “Surprise Billing”?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or must pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network. “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 towards your annual out-of-pocket limit. “Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care – like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You Are Protected From Balance Billing For: Emergency Services
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 balanced 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. North Dakota does not offer any extra protection for balance billing. The Federal guidelines are what must be followed.
Certain Services At An In-Network Hospital Or Ambulatory Surgical Center
When you get services from an in-network hospital or ambulatory surgical center, certain providers may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
When Balance Billing Isn't Allowed, You Also Have The Following Protections
1. 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.
2. Your health plan generally must:
2.1. Cover emergency services without requiring you to get approval for services in advance (prior authorization).
2.2. Cover emergency services by out-of-network providers.
2.3. 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.
2.4. 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, you may contact North Dakota Insurance Department at 701- 328-2440 or visit their website at www.insurance. nd.gov.
You Have The Right To Receive A “Good Faith Estimate” Explaining How Much Your Medical Care Will Cost
Under the Surprise billing legislation, health care providers need to give patients who don’t have insurance or who are not using insurance an estimated cost for the medical items or services provided. Provided the appointment for the estimate is scheduled for a minimum of 3 days in advance. 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.
1. Make sure your health care provider gives you a Good Faith Estimate in writing at least 3 business days before your scheduled appointment.
2. If you receive a bill that is more than $400 of your Good Faith Estimate, you can dispute the bill.
3. Make sure to save a copy of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.CMS.gov/NoSurprises or call 1-800- 985-3059.