If you have commercial insurance, Federal and New York State law may protect you from balance billing for emergency services and Surprise bills from out-of-network providers.
Is your bill a “surprise bill” from an out-of-network provider?
A surprise bill is an unexpected bill you receive from a health care provider or facility who is out-of-network with your health insurance plan. Your health plan may cover none or only part of the out-of-network cost, and the provider or facility may bill you for the difference between the billed amount and the amount your health plan paid. This is called “balance billing.”
The NO SURPRISES ACT gives everyone some level of protection against surprise medical bills.
- Everyone means people with any kind of health insurance and people who are uninsured or choose to get medical care without using their insurance (“self-pay” patients)
Not all bills that come as a surprise are surprise bills! Under the NO SURPRISES ACT, an unexpected bill from an out-of-network provider is a surprise bill if the bill is for:
- Emergency care provided by an out-of-network doctor and/or an out-of-network facility.
- Emergency care includes treatment you seek if you believe you are having a medical emergency or active labor, even if the symptoms that brought you to the emergency room later prove not to be an emergency.
- Emergency care includes in-patient doctor or hospital services received after an emergency room visit, also known as post-stabilization care, unless you provide consent to receive out-of-network care.
- Post-stabilization care is considered emergency care until a physician determines you can travel safely to another in-network facility.
- Non-emergency services provided by certain out-of-network providers at hospitals, hospital outpatient departments, and ambulatory surgical centers.
- This does not include birthing centers, clinics, hospice, addiction treatment facilities, nursing homes, or urgent care centers.
- You can waive this protection by signing a Notice and Consent Form for most types of care.
- Out-of-network supplemental care received during emergency or non-emergency care.
- Supplemental care is performed by anesthesiologists, radiologists, pathologists, and assistant surgeons.
- Out-of-network air ambulance rides.
- Out-of-network care that you received because you relied on misinformation about a provider’s network status in your health plan’s provider directory.
If your health insurance plan is regulated by New York State, then under New York’s Surprise Bill and Emergency Services law, you are ALSO protected from an out-of-network surprise bill if: Your in-network provider referred you to an out-of-network provider and:
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- You did not sign a written consent that you knew the services were out-of-network and would not be covered by your health plan; AND
- During a visit with your participating doctor, a non-participating provider treats you; OR
- Your in-network doctor takes a specimen from you in the office (for example, blood) and sends it to an out-of-network laboratory or pathologist; OR
- For any other health care services when referrals are required under your plan.
What are NOT surprise medical bills?
Bills for the following types of care are NOT surprise bills under NY state and federal law:
- Services your plan denies coverage for as not medically necessary or experimental.
- You can still challenge the plan’s decision through your plan’s appeals process.
- Care you choose to receive from an out-of-network provider instead of from an available in-network provider.
- Out-of-network balance bills for ground ambulance rides, except if you have NY regulated insurance.
- Out-of-network balance bills for non-emergency services provided in certain facilities such as birthing centers, clinics, hospice, addiction treatment facilities, nursing homes, or urgent care centers
If you believe you have received a surprise bill, please read the “What to do if you think you got a surprise medical bill” one pager.
If you have questions or need help with an emergency service or Surprise Bill, please contact CHA at 888-614-5400.