Your Rights and Protections Against Surprise Medical Billing

Effective 1/1/2022

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

What is balance billing (sometimes called surprise billing or a surprise bill notice)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

“Surprise billing”, or a surprise bill notice, is an unexpected balance bill. This can happen when you can’t control who is involved in your care— like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

You are protected from balance billing for:

Certain services at an in-network hospital or ambulatory center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to services such as emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

Consumers in New York are protected from surprise bills when treated by an out-of-network doctor at a participating hospital or ambulatory surgical center in their health plan’s network.

Additionally, consumers with health insurance coverage provided by an insurer or HMO are protected from surprise bills when a participating doctor refers them to a non-participating provider. Consumers in New York are also protected from bills for emergency services in hospitals, including inpatient care following emergency room treatment.

When balance billing isn’t allowed, you also have the following protections:

You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

Surprise Bill Notice

If you think you’ve been wrongly billed, you may contact the New York State Independent Dispute Resolution (IDR). You can visit the following New York Department of Financial Services website for additional information regarding your rights on “Surprise Medical Bills.” https://www.dfs.ny.gov/consumers/health_insurance/surprise_medical_bills.

If you need help completing a NYS IDR application, call (800) 342-3736 or email Surprisemedicalbills@dfs.ny.gov.

Visit www.cms.gov/nosurprises for more information about your rights under federal law. Federal phone number for information and complaints: 1-800-985-3059.

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