Beginning January 1, 2022, health care providers and facilities must provide a good faith estimate of expected charges to uninsured consumers, or to insured consumers if they don't plan to have their health plan help cover the costs (self-paying individuals).

 

You are generally considered an uninsured or self-pay individual if you do not have health insurance, or do not plan to use your insurance to pay for a medical item or service. If you are an uninsured or self-pay individual, a provider or facility must give you a “Good Faith Estimate" detailing what you may be charged before you receive the item or service.

 

The Good Faith Estimate Will Include:

 

• A list of items and services that the scheduling provider or facility reasonably expects to provide you for that period of care.

​Beginning in 2023, a list of items and services and their associated costs, that can be reasonably expected to be given to you by another provider or facility involved in your care (a co-provider or co-facility).

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• Applicable Diagnosis and Service Codes.

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• Expected Charges or Costs Associated with Each Item or Service.

​A notification that if the billed charges are higher than the good faith estimate, you can ask your provider or facility to update the bill to match the good faith estimate, ask to negotiate the bill, or ask if there is financial assistance available.

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• Information on how to dispute your bill if it is at least $400 higher for any provider or facility than the good faith estimate you received from that provider or facility.

​The purpose of this document is to let you know about your protections from unexpected medical bills. It also asks whether you would like to give up those protections and pay more for out-of-network care.

 

IMPORTANT: You aren’t required to sign this form and shouldn’t sign it if you didn’t have a choice of health care provider when you received care. You can choose to get care from a provider or facility in your health plan’s network, which may cost you less. If you’d like assistance with this document, ask your provider or a patient advocate. Take a picture and/or keep a copy of this form for your records. You’re getting this notice because this provider or facility could be out of network in your health plan’s network. This means the provider or facility might not have an agreement with your plan.

 

Getting Care from This Provider or Facility Could Cost You More.

 

If your plan covers the item or service you’re getting, federal law protects you from higher bills:

 

When you get emergency care from out-of-network providers and facilities, or when an out- of-network provider treats you at an in-network hospital or ambulatory surgical center without your knowledge or consent.

 

Ask your health care provider or patient advocate if you need help knowing if these protections apply to you. If you sign this form, you may pay more because:

1. You are giving up your protections under the law.

2. You may owe the full costs billed for items and services received.

 

Your health plan might not count any of the amount you pay towards your deductible and out-of-pocket limit. Contact your health plan for more information.

 

For more information: https://www.marylandattorneygeneral.gov/Pages/CPD/HEAU/NSA.aspx