January 9, 2025 (press release) –
The Centers for Medicare & Medicaid Services will host a webinar Jan. 16 at 1 p.m. ET to provide an update on the No Surprises Act Good Faith EstimateWhat is Considered “Health Insurance”? Determining When Uninsured (or Self-Pay) Good Faith Estimate Rules Apply What is a Good Faith Estimate? A good faith estimate (GFE) is an estimate of expected charges for an item or service that a patient has scheduled or an item or service for which a patient has requested a cost estimate.1 Health care providers and facilities must generally provide a GFE to uninsured (or self-pay) individuals upon scheduling health care items or services or upon an individual’s request. This fact sheet is intended to help providers and facilities determine whether a patient is uninsured (or self-pay) and entitled to receive a GFE.2 For more information about GFE requirements for uninsured (or self-pay) individuals, please see Guidance on Good Faith Estimates and the Patient-Provider Dispute Resolution (PPDR) Process for Providers and Facilities. When must providers and facilities give uninsured (or self-pay) individuals a GFE? Providers and facilities must give an uninsured (or self-pay) individual a GFE upon request or for items or services scheduled 3 or more business days in advance. For items or services scheduled fewer than 3 business days before the date of service, a GFE is not required. For example, a GFE is not required in emergency situations, walk-in appointments, or where care is scheduled 1 or 2 business days in advance. For items and services scheduled 3 or more business days before the date of service, GFEs must be provided within the following timeframes: 1 Public Health Service Act section 2799B-6, as added by section 112 of title I of Division BB of the Consolidated Appropriations Act, 2021. 2 This fact sheet doesn’t address GFE requirements that apply in the case of individuals enrolled in a group health plan, group or individual health insurance coverage offered by a health insurance issuer, or FEHB plan who seek to have a claim for the item or service submitted to their plan or coverage. For more information, see Guidance for Good Faith Estimates Part 1, available at https://www.cms.gov/cciio/resources/regulations-and- guidance/downloads/guidance-good-faith-estimates-faq.pdf. It also doesn’t address the GFE that an out-of-network provider or facility must furnish as part of asking for an individual's written consent to waive surprise billing protections under the No Surprises Act. See 45 CFR § 149.420(d)(2). For more information about this requirement, see The No Surprises Act’s Prohibitions on Balancing Billing, available at https://www.cms.gov/files/document/a274577-1a-training-1-balancing-billingfinal508.pdf. Triggering Event GFE must be provided within: Item or service scheduled 3-9 business days before the 1 business day from the date of date of service scheduling Item or service scheduled 10 or more business days 3 business days from the date of before the date of service scheduling Cost estimate for an item or service requested 3 business days from the date of the request Note that providers and facilities must consider any discussion or question from an individual about the potential costs of items or services under consideration as a request for a GFE. Who is considered “uninsured” and who is considered “self-pay” for GFE purposes? An uninsured individual is someone who is not enrolled in a group health plan, group or individual health insurance coverage, federal health care program, or a Federal Employees Health Benefits (FEHB) plan. Examples of federal health care programs include: • Medicare (including Medicare Advantage plans) • Medicaid (including Medicaid managed care plans) • The Children's Health Insurance Program (CHIP) • TRICARE • Health coverage through enrollment in the Department of Veterans Affairs (VA) Health Care System Examples of group health plans and group or individual health insurance coverage include: • A job-based group health plan (including through a spouse or parent), such as one sponsored by: o A private employer, including Multiple Employer Welfare Arrangements (MEWAs) o A state or local government employer o A labor union for its union members and their families o A Tribal government o The Federal Government (e.g., through the FEHB Program) o A church employer or an employer that is a convention or association of churches (note that this is different from a health care sharing ministry, which is not limited to church employees) o A small employer that offers a qualified health plan through the Small Business Health Options Program (SHOP) Marketplace • Individual health insurance coverage, including: o A health plan bought through a federal or state health insurance Marketplace o A policy purchased directly from a health insurance issuer • A fully-insured student health plan (i.e., where an insurance company bears the risk as opposed to the school) A self-pay individual is someone who is enrolled in a group health plan, group or individual health insurance coverage, or FEHB plan, but who does not want to have a claim submitted to their plan or coverage for the item or service. Note that an individual who is enrolled in a federal health care program (such as Medicare or Medicaid, as described above) but who does not want to have a claim submitted to their plan or coverage for the item or service is not considered to be a self-pay individual. Are individuals covered under federal health care programs entitled to an uninsured (or self-pay) GFE if their federal health care program doesn’t cover a specific item or service? No. Individuals covered under federal health care programs such as the ones described above (e.g., Medicare and Medicaid) are not entitled to a GFE, even if the program does not cover the item or service or if they do not want to have a claim submitted for the item or service. (See definition of self-pay individual above.) Is an uninsured (or self-pay) GFE required if an individual is enrolled in coverage through a health care sharing ministry; a farm bureau plan; a self-funded student health plan; or a short-term, limited-duration insurance plan? In general, yes. There are types of plans and coverage that provide payment for health care expenses but are not considered group health plans, group or individual health insurance coverage, federal health care programs, or FEHB plans. Some examples of these include health care sharing ministries, farm bureau plans, self-funded student health plans, and short-term, limited-duration insurance. An individual enrolled in one of these types of coverage (and not also enrolled in a group health plan, group or individual health insurance coverage, federal health care program, or FEHB plan) is considered uninsured for purposes of the GFE requirements and must be given an uninsured (or self-pay) GFE, if otherwise required. Health care sharing ministries. Health care sharing ministries are programs in which members share a common set of ethical or religious beliefs and share medical expenses among members in accordance with those beliefs. They are often associated with religious groups, though they do not have to be. Health care sharing ministries generally are not health insurance plans or coverage. Note that health care sharing ministries are different from church plans, which are offered by a church or association of churches to their employees and are considered group health plans. Short-Term, Limited-Duration Insurance. Short-term, limited-duration insurance is a type of insurance that is designed to fill temporary gaps in coverage when an individual is transitioning from one source of coverage to another, such as an individual who is between jobs. These types of health insurance products do not count as health insurance plans or coverage for GFE purposes. Farm bureau health plans. Farm bureau health plans are only available to members of a state’s farm bureau, though an individual does not necessarily need to be affiliated with the agricultural industry to become a member. These plans offer health benefits but are generally not subject to a state’s insurance laws and do not count as health insurance plans or coverage for GFE purposes. Self-funded student health coverage. Self-funded student health coverage is a type of plan offered to college students where the higher education institution assumes the risk for the payment of medical expenses. These plans are different from fully funded student health plans, where the insurance company pays toward claims. These plans do not count as health insurance plans or coverage for GFE purposes. How can I determine whether someone’s health coverage is a group health plan, group or individual health insurance coverage, federal health care program, or a FEHB plan? Providers and facilities must take reasonable steps to determine if the individual is enrolled in a group health plan, group or individual health insurance coverage, federal health care program, or FEHB plan, such as: • Asking for the individual’s understanding of their insurance status. • Asking the individual for the name and policy number of the product they are enrolled in. • Reviewing the individual’s insurance card for key terms that suggest the product is a group health plan, group or individual health insurance coverage, federal health care program, or FEHB plan, as further discussed below. • Educating staff about the types of plans and coverage that are, and are not, considered a group health plan, group or individual health insurance coverage, federal health care program, or FEHB plan. • Contacting the plan, issuer, FEHB carrier, or other organization listed on the individual’s health insurance ID card to ask whether the product is a group health plan, group or individual health insurance coverage, federal health care program, or FEHB plan, and to verify the individual’s enrollment. How can I tell if someone is enrolled in a group health plan, group or individual health insurance coverage, federal health care program, or FEHB plan based on their health insurance ID card? Typically, an individual’s health insurance ID card will provide clues that can help you determine what type of coverage the individual is enrolled in. For example, most health insurance ID cards for group health plans and group and individual health insurance coverage will include certain information. If a patient’s ID card does not include the following information, it may be a sign that the coverage is not a health insurance plan or coverage for uninsured (or self-pay) GFE purposes: • A deductible • An out-of-pocket maximum limitation • A telephone number and website address or QR code where the individual may seek consumer assistance information A health insurance ID card from a health care sharing ministry or short-term, limited-duration insurance may include some of the above information. We encourage you to call the number listed on the ID card if you are unsure of whether the coverage is a group health plan, group or individual health insurance coverage, federal health care program, or FEHB plan. Below are examples of cards from programs that are not group health plans, group or individual health insurance coverage, federal health care programs, or FEHB plans. If an individual’s health insurance ID card looks like any of the samples illustrated below, they may be uninsured for GFE purposes and entitled to an uninsured (or self-pay) GFE. Sample Health Care Sharing Ministry Card Front of Card Health care sharing ministries may include the term “Ministries” or “Health Share” in their name. They may also refer to “Pre-Notification” requirements for certain services (this is different from prior authorization or prior approval). The inclusion of these terms on an ID card may be a sign that the individual is considered uninsured for GFE purposes. Back of Card The member card will often provide a disclaimer stating that it is NOT a form of insurance. Note that not every ID card from a health care sharing ministry will include this type of disclaimer. We encourage you to look for other indicators or call the number listed on the card. Sample Short-Term, Limited-Duration Insurance Card Member cards for short-term, limited-duration insurance may include a statement either on the front or back of the card that this is a “short-term” product. The inclusion of this term on an insurance card is a sign that the coverage does not count as a health insurance plan or coverage for GFE purposes. Sample Farm Bureau Insurance Card Farm bureau health plans will likely include the term “farm bureau” in their name and indicate which state they serve (for example, “Oklahoma Farm Bureau”). Additional GFE guidance and resources: • Sample GFE template: https://www.cms.gov/files/document/good-faith-estimate- example.pdf. • FAQs about GFEs for Uninsured (or self-pay) Individuals: https://www.cms.gov/marketplace/resources/regulations- guidance#Good_Faith_Estimates. • CMS’ No Surprises Act webpage: https://www.cms.gov/nosurprises. requirements for uninsured and self-pay patients. Experts will discuss the recent GFE FAQsFAQS ABOUT CONSOLIDATED APPROPRIATIONS ACT, 2021 IMPLEMENTATION – GOOD FAITH ESTIMATES (GFEs) FOR UNINSURED (OR SELF-PAY) INDIVIDUALS – PART 5 Q1: Are providers and facilities required to provide uninsured (or self-pay) GFEs to individuals who are members of health care sharing ministries and not enrolled in other health coverage? A1: In general, yes. Section 2799B-6 of the Public Health Service (PHS) Act (as added by section 112 of the No Surprises Act) and 45 CFR 149.610 generally require a provider or facility to provide a GFE to an uninsured (or self-pay) individual. An individual is considered uninsured for this purpose if they are not enrolled in a group health plan, group or individual health insurance coverage, federal health care program, or Federal Employees Health Benefits (FEHB) plan. Individuals who are members of health care sharing ministries and not enrolled in one of these other types of health coverage are considered uninsured for GFE purposes, and providers and facilities must provide them with a GFE for uninsured (or self-pay) individuals if otherwise required. Other plans or coverage that an individual may have and still be considered uninsured for GFE purposes are short-term, limited-duration insurance, self-funded student health plans, and farm bureau plans. In general, an individual enrolled in one of these types of coverage (and not also enrolled in a group health plan, group or individual health insurance coverage, federal health care program, or FEHB plan) is considered uninsured for purposes of the GFE requirements, and providers and facilities must give them an uninsured (or self-pay) GFE, if otherwise required. Q2: Are providers and facilities required to verify with an individual’s plan or issuer whether the individual is enrolled in a group health plan, group or individual health insurance coverage, federal health care program, or FEHB plan? A2: 45 CFR 149.610(b)(1)(i)-(ii) requires providers and facilities to determine if an individual is uninsured (or self-pay) by inquiring if they are enrolled in a group health plan, group or individual health insurance coverage, federal health care program, or FEHB plan and are seeking to have a claim submitted to their plan or coverage. As part of that inquiry, providers and facilities must take reasonable steps to determine if the individual is enrolled in such plan or coverage. Taking reasonable steps may include educating staff about the types of plans and coverage that are, and are not, considered group health plans, group or individual health insurance coverage, federal health care programs, or FEHB plans. For individuals who represent themselves as insured, taking reasonable steps may include asking them for the name and policy number of the product they are enrolled in and reviewing their insurance card for key terms that suggest they may not be enrolled in a group health plan, group or individual health insurance coverage, federal health care program, or FEHB plan. Providers are encouraged, but not required, to verify the individual’s enrollment by contacting the plan, issuer, or other organization listed on the card to determine whether the product is a group health plan, group or individual health insurance coverage, federal health care program, or FEHB plan. For more information about determining whether an individual is considered insured, uninsured, or self-pay for GFE purposes, see the fact sheet What is Considered “Health Insurance”? Determining When Uninsured (or Self-Pay) Good Faith Estimate Rules Apply, available at https://www.cms.gov/files/document/fact-sheet- what-is-considered-health-insurance.pdf. Q3: Does the requirement to provide GFEs to uninsured (or self-pay) individuals apply to dental and vision providers and facilities? A3: Yes. Dental and vision providers and facilities are generally subject to the requirement to provide GFEs to uninsured (or self-pay) individuals.1 Q4: Are GFEs required when students who are not licensed providers furnish health care items or services under the supervision of a licensed provider or facility (such as a university clinic)? A4: Yes. Where a licensed provider or facility supervises an unlicensed student in furnishing health care items or services, such as in a university clinic, the responsibility to provide a GFE lies with the licensed provider or facility. If an uninsured (or self-pay) individual schedules an item or service to be furnished by (or requests a GFE from) the licensed provider or facility, including through supervision of an unlicensed student, the licensed provider or facility must provide a GFE (either directly or through a representative, such as their administrative staff or the unlicensed student), as otherwise required. GFEs in this situation must include the name, National Provider Identifier, and Tax Identification Number of the licensed provider or facility that would be billing the uninsured (or self-pay) individual. If the licensed provider or facility does not expect to bill the uninsured (or self-pay) individual for items and services, it may provide an abbreviated GFE as outlined in FAQs about Consolidated Appropriations Act, 2021 Implementation – Good Faith Estimates (GFEs) for Uninsured (or Self-pay) Individuals – Part 4, available at https://www.cms.gov/files/document/faqs-good-faith-estimate-uninsured-self-pay-part-4.pdf. Q5: Are uninsured (or self-pay) GFEs for items or services scheduled fewer than 3 business days before the date of service eligible for the patient-provider dispute resolution (PPDR) process? A5: No. Pursuant to section 2799B-6 of the PHS Act and 45 CFR 149.610, a provider or facility is not required to provide a GFE to an uninsured (or self-pay) individual who schedules an item or service fewer than 3 business days before the date the item or service is expected to be furnished, such as in the case of walk-in appointments and emergencies. A provider or facility who provides such a GFE does so voluntarily. Section 2799B-7 of the PHS Act establishes the PPDR process that allows an uninsured (or self- pay) individual who receives a GFE from a provider or facility pursuant to section 2799B–6 of the PHS Act to challenge a bill that is substantially in excess of the GFE. Because voluntary GFEs are not provided pursuant to the requirements in section 2799B-6 of the PHS Act, they are 1 See definition of “health care provider” and “health care facility” at 45 CFR § 149.610(a)(2)(vii-viii) not eligible for the PPDR process. This is true regardless of whether the individual’s final bill exceeds the voluntary GFE by $400 or more. Q6: Should a provider or facility reschedule an appointment for an individual if the provider or facility is unable to provide a required uninsured (or self-pay) GFE within the timeframes set forth in section 2799B-7 of the PHS Act and implementing regulations? A6: Providers and facilities are required under section 2799B-6 of the PHS Act and 45 CFR 149.610(b)(1)(vi) to provide uninsured (or self-pay) GFEs within certain specified timeframes. For an item or service scheduled between 3 and 9 business days in advance, a GFE must be provided no later than 1 business day after the date of scheduling. For an item or service scheduled 10 or more business days in advance, a GFE must be provided no later than 3 business day after scheduling. When a GFE is requested by an uninsured (or self-pay) individual, the GFE must be provided no later than 3 business days after the date of the request. Delaying care does not relieve a provider or facility of its obligation to provide a GFE within these timeframes. As such, HHS strongly encourages providers or facilities not to delay patient care solely because the provider or facility is unable to provide a required GFE within the timeframes set forth in section 2799B-6 of the PHS Act and implementing regulations, or solely because the patient has not received their GFE by the date of service (such as in the case of delayed paper mail), unless the delay is requested by the patient. Q7: What does “business day” mean? A7: As described in Q6 above, a GFE generally must be provided within either 1 or 3 business days after an individual schedules an item or service or requests a GFE. HHS considers “business days” for GFE purposes to include Monday through Friday, not including federal holidays. The GFE must be provided by 11:59PM on the business day that it is due pursuant to 45 CFR 149.610(b)(vi). For example, if an uninsured (or self-pay) individual schedules an item or service on Monday, January 3 at 3:00PM to be provided on Thursday, January 6 at 12:00PM, the provider or facility must provide a GFE no later than 11:59PM on Tuesday, January 4 because the item or service was scheduled between 3 and 9 business days in advance, requiring the provider or facility to provide the GFE within 1 business day after the date of scheduling. States that are primary enforcers of GFE requirements may exclude both state and federal holidays from the definition of “business days” for GFE purposes. HHS will not determine that a state is failing to substantially enforce GFE requirements if it takes such an approach. Q8: If a consumer requests a GFE from the wrong point of contact in a provider’s office or facility, is the provider or facility responsible for ensuring the consumer is directed to the right point of contact? A8: Yes, if it would be reasonable for the consumer to expect that they have made a valid request for a GFE and that the person receiving the request would be an appropriate agent of the provider or facility. Section 2799B-6 of the PHS Act requires a provider or facility to provide a GFE “if requested by the individual.” HHS expects providers and facilities to make good faith efforts to satisfy this requirement and not impose an unreasonable burden on an individual seeking to obtain a GFE. For example, if an individual requests a GFE from someone whose position with a provider or facility relates to patient care, scheduling, billing, or other similar functions, it would be reasonable for the patient to expect that they have made a valid request for a GFE and that the person receiving the request would be an appropriate agent of the provider or facility. In that case, the person receiving the request must transmit the request, or direct the requesting individual, to the appropriate person or department responsible for providing GFEs, in a manner sufficiently timely for the GFE to be provided under the timeframes specified in Q6. with a focus on implications for providers and facilities. REGISTER NOW
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