Out-of-Network Cost & Coverage – CDPHP
understanding the command outside the network
on december 27, 2020, the no surprises act (nsa) became law as part of the consolidated appropriations act of 2021 and goes into effect on january 1, 2022. nsa protections are like the that are already offered in new york. however, federal regulations extend new york’s protections in certain circumstances.
the nsa states that the federal independent dispute resolution (idr) process will apply and may be used to determine the out-of-network rate for emergency services in a hospital emergency department or emergency department independent and non-emergency items and services provided by non-participating providers during a visit to a participating health care facility when a model all-payer agreement does not apply under social security law § 1115a or “specified state law” .
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new york has an idr process that applies to out-of-network emergency services, including inpatient services following an emergency room visit, at hospital facilities, and surprise bills at participating hospitals or ambulatory surgical centers and for services referred by a participating physician. Since new york has a specific state law, the new york idr process will still apply to out-of-network emergency services and unexpected bills.
surprise bills: what they are and what to do with them
what is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may have certain out-of-pocket costs, such as a copay, coinsurance, or deductible. You may have other costs or may have to pay the entire bill if you see a provider or visit a health care facility that is not in your health plan’s network.
“Out-of-network” describes providers and facilities that have not signed a contract with your health plan. Out-of-network providers may be allowed to bill you for the difference between what your plan has agreed to pay and the full amount charged for a service. this is called “balance billing.” This amount is likely to be more than your in-network costs for the same service and may not count toward your annual out-of-pocket limit.
“surprise billing” 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 schedule a visit at a network facility but receive unexpected treatment from an out-of-network provider.
you are protected from balance billing of:
If you have an emergency medical condition and obtain emergency services from an out-of-network provider or hospital, the most the provider or facility can bill you is your plan’s in-network cost-sharing amount (such as copays and coinsurance). you cannot receive a balance bill for these emergency services. this includes services you may receive after you are in stable condition, unless you consent in writing and waive your protections against being balance billed for these services. post-stabilization services. If New York law applies to your health plan (for example, coverage that is not self-funded by your employer and was purchased in New York), you cannot waive your protections and you cannot be balance billed for post-stabilization services. . Your health plan ID card will tell you if New York law applies.
certain services at a network hospital or ambulatory surgical center
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When you receive services from an in-network hospital or ambulatory surgery center, certain providers may be out-of-network. in these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. this applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, surgical assistant, hospitalist or intensivist services. these providers cannot balance bill you and cannot ask you to waive your protections against being balance billed.
If you obtain other services at these in-network facilities, the out-of-network providers cannot balance bill you unless you consent in writing and waive your protections. if new york law applies to your health plan, you cannot waive your protections for these other services if they are a surprise bill. you may need to sign a form to make sure you are not balance billed. surprise bills are when you are in a network hospital or ambulatory surgical center and a participating doctor was not available, a non-participating doctor provided services without your knowledge, or unforeseen medical services were provided.
services referred by your doctor within the network
if new york law applies to your health plan, surprise bills include when your in-network doctor refers you to an out-of-network provider without your consent (including lab and pathology services). these providers cannot balance-bill you and not ask you to waive your protections against being balance-billed. you may need to sign a form to make sure you are not balance billed. Your health plan ID card will tell you if New York law applies.
what to do if you get a surprise bill
The new law gives patients who receive surprise bills the right to appeal through an independent dispute resolution entity (idre), which will make a decision within 30 days of receiving the request.
if you are insured through a commercial or state funded cdphp® plan, by completing an assignment of benefits form. send a copy of the form to the physician who provided the services and a copy to cdphp by emailing it to us using the secure member site, or mailing it to us at:
cdphp 500 patron creek blvd. albany new york 12206
cdphp will dispute the bill on your behalf and you will be responsible only for your share of the in-network costs for covered services.
if you have health coverage through a self-insured employer or if you are uninsured, you can dispute a bill through new york state’s independent dispute resolution process .
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You’ll never have to give up your balance billing protections. You also don’t have to get care outside the network. You can choose a provider or facility in your plan’s network.
When balance billing is not allowed, you also have the following protections:
You are only responsible for paying your share of the cost (such as copayments, coinsurance, and deductibles that you would pay if the provider or facility were in-network). Your health plan will pay out-of-network providers and facilities directly.
Your health plan generally must:
cover emergency services without needing to get approval for the services in advance (prior authorization).
cover emergency services from out-of-network providers.
Base what you owe the provider or facility (cost sharing) on what you would pay a 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.
if you believe you have been billed incorrectly and your coverage is subject to new york law (“fully insured coverage”), contact the new york state department of financial services at ( 800) 342-3736 or [email protected]. Visit www.dfs.ny.gov for information about your rights under state law.
contact cms at 1-800-985-3059 for self-financed coverage or coverage purchased outside of new york. Visit www.cms.gov/nosurprises/consumers for information on your rights under federal law.