A new health care law starting Jan. 1, 2022
What is it?
We hear plenty of stories in the news of people getting huge unexpected bills after needed medical procedures. Perhaps you have even experienced this yourself. It happens most often in the hospital – a provider you saw is out of network, even though the hospital itself is in network with your insurance, or something you thought should be covered was not – and you get stuck with an outrageous, unexpected bill. Or perhaps you don’t have insurance, and had to get a procedure done and had no guidance from the start what it all would cost. To counter this, as part of the COVID funding bill of Dec 2020, congress enacted a law that requires that all medical providers give “Good Faith Estimates” prior to treatment clearly stating what is being treated (diagnosis and procedure codes) and what the estimated cost and duration of treatment will be. In other words, you now have the legal right to receive an estimate explaining how much your medical care will cost.
Who’s it for?
Right now, it only applies to services that are provided out of network, which means not covered by insurance. Either you are seeing a provider that is not in-network with your insurance plan OR you are not using insurance to cover the cost of the service.
What’s it say?
Under the law, out-of-network health care providers need to give you an estimate of the bill for medical items and services. You have the following rights under this law:
- You have the right to receive a Good Faith Estimate (GFE) 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.
- Your health care provider must provide a GFE in writing at least 1 business day before your medical service or item (except in cases of emergency). You can also ask for a Good Faith Estimate before you schedule an item or service.
- If you receive a bill that is at least $400 more than your GFE, you can dispute the bill, so make sure to save a copy or picture of your Good Faith Estimate.
How does this apply to mental health?
Unlike many medical procedures, mental health treatment is often an ongoing service, and it can be hard to estimate how long treatment will take. Many factors are at play, including severity of symptoms, trauma history, and everyday life problems that impact outcome in therapy. And before treatment starts, we often don’t have a diagnosis code, or a sense of what your goals are, so it is hard to determine how long treatment will take. Because of this, your Good Faith Estimate often will be based on a year of weekly services. Remember, it is only an estimate. Treatment planning is often a part of the first few sessions of treatment, and we can discuss then how long treatment may take as we get going. We will continue to reassess this as treatment continues, so we may update your GFE as needed.
Want to find out more?
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises