Surprise Billing Law New York Protects Consumers

New York's surprise billing law is a game-changer for consumers. The law protects patients from unexpected medical bills when they receive care from out-of-network providers.

The law limits surprise billing to 125% of the Medicare rate, which is significantly lower than what out-of-network providers often charge. This means you'll pay less out of pocket for unexpected medical expenses.

In New York, surprise billing is only allowed in emergency situations, and even then, the law requires providers to give patients a clear estimate of the costs beforehand. This transparency is a huge step forward in protecting consumers from financial shock.

The law also requires health insurance companies to cover out-of-network emergency services, so you won't be left with a huge bill even if you received care from an out-of-network provider.

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You're protected from surprise billing or balance billing in certain situations. These include emergency services and certain services at an in-network hospital or ambulatory surgical center. You can't be balance billed for emergency services, including those you get after you're in stable condition, unless you give written consent.

Emergency services include services from an out-of-network provider or facility when you have an emergency medical condition. The most the provider or facility can bill you is your plan's in-network cost-sharing amount. You can't be balance billed for these emergency services.

Certain services at an in-network hospital or ambulatory surgical center also have protections. These services include emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. Out-of-network providers can't balance bill you for these services.

Out-of-network providers can only bill you for the difference between what your plan agreed to pay and the full amount charged for a service if you give written consent. This is called balance billing. You're never required to give up your protections from balance billing.

Here are the protections you have when balance billing isn't allowed:

You're protected from balance billing for emergency medical conditions, and out-of-network providers can't bill you more than your plan's in-network cost-sharing amount.

In-network hospitals and ambulatory surgical centers may have out-of-network providers, but they can't balance bill you for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, and intensivist services.

You can't give up your protections from balance billing for these services, even if your insurance ID card says "fully insured coverage."

The federal government has established several consumer protection agencies to safeguard consumers from unfair business practices.

The Consumer Financial Protection Bureau (CFPB) was created in 2010 to regulate consumer financial products and services, such as credit cards and mortgages. It's responsible for enforcing federal consumer financial laws and providing education and resources to consumers.

The CFPB has implemented rules to prevent predatory lending practices, including a rule that prohibits lenders from making loans that consumers cannot afford to repay. This rule has helped to prevent millions of dollars in debt from being incurred by consumers who cannot afford to pay it back.

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The Federal Trade Commission (FTC) is another agency that protects consumers from unfair business practices. The FTC has brought cases against companies that have engaged in deceptive marketing practices, such as making false claims about the benefits of a product or service.

The FTC has also established guidelines for businesses to follow when making claims about their products or services. These guidelines include requirements for providing clear and accurate information to consumers.

The FTC has also taken action against companies that have engaged in unfair business practices, such as charging consumers for services they did not receive.

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You're protected from balance billing in certain situations. If you have an emergency medical condition and get emergency services from an out-of-network provider or hospital, the most they can bill you is your plan's in-network cost-sharing amount.

Emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, and intensivist services at an in-network hospital or ambulatory surgical center can't balance bill you. These providers can't ask you to give up your protections not to be balance billed.

You can't be balance billed for these services, even if you're at an in-network hospital or ambulatory surgical facility and a participating doctor was not available. This includes lab and pathology services referred by your in-network doctor without your consent.

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.

Balance billing can be a nightmare, especially if you're not expecting it. It happens when you see an out-of-network provider or facility that hasn't signed a contract with your health plan to provide services.

You might owe certain out-of-pocket costs like a copayment, coinsurance, or deductible, but with balance billing, the out-of-network provider can bill you for the difference between what your plan pays and the full amount charged for a service. This amount is likely more than in-network costs for the same service.

Surprise billing is essentially an unexpected balance bill, and it can happen when you can't control who is involved in your care, like in an emergency or when you're treated by an out-of-network provider at an in-network facility.

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You have the right to be protected from surprise medical bills in New York. You can't be balance billed for emergency services, even if the provider or facility isn't in your health plan's network.

In emergency situations, the most you'll be billed is your plan's in-network cost-sharing amount, such as copayments and coinsurance. This applies to services you receive after you're in stable condition, unless you give written consent.

Emergency services include things like ambulance rides, emergency room visits, and urgent care visits. These services are covered, even if the provider or facility isn't in your network.

You also have protections when you receive services at an in-network hospital or ambulatory surgical center. Certain providers, like emergency medicine doctors or radiologists, can't balance bill you, even if they're out-of-network.

Here are the services that are protected from balance billing at in-network facilities:

If you're balance billed, you're only responsible for paying your share of the cost, like copayments and coinsurance. Your health plan will pay out-of-network providers and facilities directly.

You're never required to give up your protections from balance billing, and you're not required to get care out-of-network. You can choose a provider or facility in your plan's network.

The No Surprises Act was enacted in December 2020 to provide federal consumer protections against surprise medical bills. This law was included in omnibus legislation funding the federal government for fiscal year 2021 and providing stimulus relief for the COVID-19 pandemic.

It took nearly two years of Congressional debate to pass this law, which aimed to address the issue of surprise medical bills that have been a concern for many families. 2 in 3 adults worry about unexpected medical bills, more than the number worried about affording other health care or household expenses.

The law contains key protections to hold consumers harmless from the cost of unanticipated out-of-network medical bills. Surprise bills can number in the millions each year, and among privately insured patients, an estimated 1 in 5 emergency claims and 1 in 6 in-network hospitalizations include at least one out-of-network bill.

Health plans that generally don’t cover out-of-network care, such as an HMO, might deny a surprise bill entirely. Or plans might pay a portion of the bill, but leave the patient liable for balance billing – the difference between the undiscounted fee charged by the out-of-network provider and the amount reimbursed by the private health plan.

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