Marianela Dornhecker, PhD (314) 669-4706; drmarianeladornhecker@gmail.com; www.marianeladornheckerphd.com

STANDARD NOTICE

“Right to Receive a Good Faith Estimate of Expected Charges”

Under the No Surprises Act

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

  • 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.

  • Make sure your health care provider gives you a Good Faith Estimate in writing at least one business day before your medical service or item. You can also ask your health care provider, and any other provider you choose 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 Good Faith Estimate, you can dispute the bill.

  • Make sure you have a copy or a picture 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 (314) 669-4706

Additionally, Missouri law requires that patients pay only their in-network cost-sharing amounts. These protections apply to any patient covered by a state-regulated insurance plan but does not apply to a liability insurance policy, workers’ compensation insurance policy, or medical payments insurance issued as a supplement to a liability policy.

Additionally, Texas law protects patients from surprise medical bills in emergencies and when a patient receives covered medical services from an out-of-network provider at an in-network facility. The law applies to state-regulated insurance plans, including the state employee or the teacher retirement systems. This law does not apply to non-emergency healthcare or medical services when a patient elects in advance and in writing to receive those services from an out-of-network provider and when the out-of-network provider provides the patient with a written disclosure.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call (314) 669-4706