Dental providers and facilities are “generally required to provide uninsured patients with a good faith estimate of expected charges” unless the patient is enrolled in an excepted benefit plan or coverage such as a stand-alone dental plan, according to the Centers for Medicare & Medicaid.
This was one of the answers the ADA received from CMS when the Association shared common questions it has received from member dentists about the No Surprises Act, also known as surprise billing.
The No Surprises Act went into effect Jan. 1, 2022. The law gives consumers billing protections when getting emergency care, nonemergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers.
Many dentists have asked the ADA about good faith estimates and whether they need to provide them.
On Feb. 22, CMS sent an email to ADA confirming that dental providers are required to provide uninsured or self-pay individuals with a good faith estimate of expected charges under [federal regulation] 45 CFR 149.610. The agency did note that providers and facilities are “generally not required to provide a good faith estimate to an individual enrolled in an excepted benefit plan or coverage such as a limited-scope dental plan, even if the individual is not enrolled in other coverage.”
“This is because such an individual is considered to be enrolled in a group health plan or health insurance coverage under the Public Health Service Act, and therefore is generally not considered uninsured,” CMS said.
The CMS also said there were two exceptions to the good faith estimate rule:
“If the excepted benefit plan or coverage does not cover a scheduled or requested item or service (for example, because the excepted benefit plan is a limited-scope vision plan and the individual is scheduling dental services), and the individual has no other coverage for the item or service, that individual is considered uninsured with respect to that item or service, and the provider or facility must give them an uninsured or self-pay good faith estimate,” the response said. “Similarly, if the individual does not seek to have a claim for the item or service submitted to their excepted benefit plan or coverage, and the individual has no other coverage for that item or service, that individual is considered self-pay with respect to that item or service, and the provider or facility must give them an uninsured (or self-pay) good faith estimate.
“In both of these cases, the individual with the uninsured or self-pay good faith estimate would be eligible to initiate the Patient-Provider Dispute Resolution process if the provider or facility’s bill is at least $400 more than the estimate in the good faith estimate.”
CMS also noted that in making the determination as to whether the individual is uninsured or self-pay, “there is no requirement in [the regulation] that providers or facilities verify coverage for each item or service with the individual’s plan or issuer. Providers and facilities may make this determination based on its inquiries of the individual under [the regulation.]”
For previous ADA News information on the No Surprises Act, read this 2022 article.
For information on all of the Centers for Medicare & Medicaid guidance on the No Surprises Act, visit CMS.gov/NoSurprises.
The ADA continues to monitor this evolving issue and will share any updates the Association receives. This article is not, and should not, be considered legal advice.
For more information on all the ADA’s advocacy efforts, visit ADA.org/Advocacy.