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No Surprises – Balance Billing Protections – Paying for Care | NewYork-Presbyterian

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 additional 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” means providers and facilities that have not signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays 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 plan’s deductible or annual out-of-pocket limit.

Reading: What is balance billing health insurance

“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. surprise medical bills can cost thousands of dollars depending on the procedure or service.

you are protected from balance billing of:

emergency services

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If you have an emergency medical condition and receive emergency services from an out-of-network provider or hospital, the most you can be billed is your plan’s in-network cost-sharing amount (such as copays, coinsurance, and deductibles). ). You cannot be balance billed for these emergency services. this includes services you may receive after you are in a stable condition, unless you consent in writing and waive your protections against receiving balanced billing for these post-stabilization services. If your insurance ID card says “fully insured coverage,” you may not give your written consent and waive your protections against being balance billed for post-stabilization services.

certain services at a network hospital or ambulatory surgical center

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, and intensivist services. these providers cannot balance bill you and cannot ask you to waive your protections against being balance billed.

If you obtain other types of services at these in-network facilities, the out-of-network providers cannot balance bill you unless you give your consent in writing and waive your protections. If your insurance ID card says “fully insured coverage,” you can not waive your protections for these other services if they are a surprise bill. 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 in-network doctor

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If your insurance ID card says “fully insured coverage,” 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 cannot ask you to waive your protections against being balance billed. you may be required to sign a form (available on the Department of Financial Services website) for full balance billing protection to apply.

You’ll never have to give up your balance billing protections. You are also not required 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 these 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 any additional costs to out-of-network providers and facilities directly.
  • Generally, your health plan must:
    • cover emergency services without requiring you to obtain prior approval for the services (also known as “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 an in-network provider or facility network and show that amount in your explanation of benefits.
    • count any amount you pay for emergency services or out-of-network services toward your in-network 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 http://www.dfs.ny.gov for information on your rights under state law.

    contact cms at 1-800-985-3059 for self-financed coverage or coverage purchased outside of new york. Visit http://www.cms.gov/nosurprises/consumers for information on your rights under federal law.

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