BronxCare Health System

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from 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”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional 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” means providers and facilities that haven’t 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 more than in-network costs for the same service and might not count toward your plan’s deductible or 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 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’re protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical 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 can bill you is your plan’s in-network cost-sharing amount. This applies to 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 types of 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 out-of-network care. You can choose a provider or facility in your plan’s network.

***See below for additional information regarding New York State Surprise Medical Bills Law

***New York State Surprise Medical Bills Law

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 You Receive Services From a Non-Participating Doctor at a Participating Hospital or Ambulatory Surgical Center, It’s a Surprise Bill if:

  • A participating doctor was not available; OR
  • A non-participating doctor provided services without your knowledge; OR
  • Unforeseen medical services were provided when you received health care services.
  • It is not a surprise bill if you chose to receive services from a non-participating doctor instead of from an available participating doctor.

When You Are Referred By Your Participating Doctor to a Non-Participating Provider, It’s a Surprise Bill if:

  • 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 participating doctor takes a specimen from you in the office (for example, blood) and sends it to a non-participating laboratory or pathologist; OR
    ◦  For any other health care services when referrals are required under your plan.

Protect Yourself From a Surprise Bill.

You will be protected from a surprise bill and you will only have to pay your in-network copayment, coinsurance, or deductible if you:

  • Sign AOB Form. Sign an Assignment Of Benefits form to allow your provider to seek payment from your health plan; AND
  • Send AOB Form and Bill. Send the assignment of benefits form to your health plan and provider and include a copy of the bill you do not think you should pay.

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

  • You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was 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 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 in-network deductible and out-of-pocket limit.

If you think you’ve been wrongly billed, you may contact:

  • BronxCare at 718-466-7245;
  • The Department of Health and Human Services (HHS) for information and complaints at: 800-985-3059; OR
  • The NYS Department of Financial Services at 800-342-3736

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