Good Faith Estimates: Who Gets Them, Why People With Medicare Usually Don't, and How Disputes Work

A Good Faith Estimate is a written estimate of expected charges that health care providers must generally give to people who are uninsured or who choose not to use their private insurance (self-pay). People enrolled in Medicare, including Medicare Advantage, aren't eligible for this estimate, even for services Medicare doesn't cover, because the Centers for Medicare & Medicaid Services (CMS) says other billing protections apply to them. For people who do qualify, if the bill is at least $400 more than the estimate, they may be able to dispute it.

Who gets a Good Faith Estimate?

CMS says that if you aren't using health insurance to pay for your care, your provider usually must give you a Good Faith Estimate if you ask for one or if you schedule a service at least 3 business days in advance.

CMS's fact sheet on what counts as health insurance explains two groups:

• Uninsured: someone not enrolled in a group health plan, group or individual health insurance, a federal health care program, or a Federal Employees Health Benefits (FEHB) plan.
• Self-pay: someone enrolled in a group health plan, individual insurance, or an FEHB plan who doesn't want a claim sent to that coverage.

Can someone with Medicare get a Good Faith Estimate?

Generally, no. CMS's fact sheet says people covered by federal health care programs, such as Medicare and Medicaid, aren't entitled to a Good Faith Estimate, even if the program doesn't cover the service or they don't want a claim submitted. CMS's decision tree lists Medicare, including Medicare Advantage, as a federal health care program and says enrollees aren't eligible because other surprise billing protections apply under these programs.

The fact sheet also lists TRICARE, Medicaid, Children's Health Insurance Program (CHIP), and coverage through the Department of Veterans Affairs (VA) health care system as federal health care programs.

What protections do people with Medicare have instead?

People with Original Medicare have other tools:

• Assignment and limiting charges. Doctors who accept assignment can't charge more than the Medicare-approved amount. Doctors who don't accept assignment are limited in how much they can charge for most covered services.
• Advance Beneficiary Notice of Noncoverage (ABN). Before giving a service Medicare may not cover, a provider may give you an ABN, which may include an estimated cost. You can choose whether to get the service.
• The Medicare Summary Notice. It shows the most a provider may bill you for covered services.
• Medicare's Procedure Price Lookup tool. It compares national average costs for some procedures in hospital outpatient departments and ambulatory surgical centers.

You can still ask any provider for a cost estimate in writing.

When might a Good Faith Estimate still matter for my family?

If you're helping a parent, it's useful to know the rule for yourself or other family members:

• An adult child without insurance getting care.
• A family member with employer coverage who chooses to pay cash for a service.
• A relative not yet on Medicare who is between jobs.

How fast do I get a Good Faith Estimate?

CMS says:

• If you schedule care 10 or more business days ahead, you get the estimate within 3 business days.
• If you schedule care 3 to 9 business days ahead, you get it within 1 business day.

Keep the estimate. CMS says you can't dispute your bill without one.

How do I dispute a bill that's higher than the estimate?

For people who qualify, CMS's dispute page says you may be eligible to dispute a bill if:

• The provider charged at least $400 more than your Good Faith Estimate.
• You have an initial bill dated within the last 120 calendar days (about 4 months).

To file, you pay a $25 non-refundable administrative fee. If the dispute is decided in your favor, CMS says the $25 is subtracted from the amount you owe the provider. CMS also says your costs won't increase because you disputed your bill.

You can start a dispute online or by mail or fax. For help, call the No Surprises Help Desk at 1-800-985-3059.

What should I do if I'm on Medicare and a bill is higher than I expected?

1. Check your Medicare Summary Notice or your plan's Explanation of Benefits (EOB). Compare the bill with the "maximum you may be billed."
2. Look for an ABN. If you signed one, compare the estimated cost on it to the bill.
3. Ask for an itemized bill.
4. Call the billing office and ask why the bill is higher.
5. Appeal if Medicare denied something you think it should cover.

Frequently asked questions

Do Medicare patients get Good Faith Estimates?

Generally, no. CMS says people enrolled in federal health care programs like Medicare aren't entitled to one, even for non-covered services.

What is the dispute threshold for a Good Faith Estimate?

CMS says you may be able to dispute if the bill is at least $400 more than the estimate.

How long do I have to dispute?

The initial bill must be dated within the last 120 calendar days.

Is there a fee to dispute?

Yes, a $25 non-refundable fee. If you win, it's subtracted from what you owe the provider.

Want help comparing a bill to what you were told?

Bill Review Coach is a monthly medical bill review service for seniors and their families. Snap a photo of the bill, your Medicare notice, and any estimate or ABN, and we'll show you what doesn't match and what to say when you call. You make the calls and write the emails; we help you know what to say.