Pay Bill(Insurance Law Sections 3217-a, 3217-b, 3217-d, 3241, 4306-c, 4324, 4325 & 4804); (Public Health Law Sections 4403 & 4408); Financial Services Law Article 6; 23 NYCRR Part 400; No Surprises Act (Pub.L. No. 116-260, 134 Stat. 1182, Division BB Section 109; 42 USC Section 300 gg et seq)
New York State and federal laws are in place to help you avoid surprise bills and unexpected expenses when receiving out-of-network care. Additionally, the laws protect you in the event that you must go out of network for a specialist or procedure when they are not available within your plan’s provider network.
Understanding Your Rights to Access Out-of-Network Care
Right to Go Out-of-Network When Independent Health Does Not Have An In-Network Provider:
- When Independent Health does not have an in-network provider with the appropriate training and experience to meet your particular health care needs, you may get approval to receive care from an out-of-network provider for no additional cost beyond what you would pay to see an in-network provider.
- Contact Independent Health to receive information on how to obtain approval to an out-of-network provider.
Right to Go Out-of-Network When Independent Health Does Have An In-Network Provider:
- Even when Independent Health does have an in-network provider with the appropriate training and experience to meet your particular health care needs, you may choose to seek medically necessary services from an out-of-network provider. However, when doing so, you will need to pay any applicable out-of-network cost according to your General Health Contract or GHC (GHC). To estimate what these out-of-network costs may be, visit http://www.fairhealthconsumer.org
- If your GHC does not provide out-of-network coverage, then services will not be covered.
See examples of what it may cost for you to go out of network.
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 applicable to in-network services.
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 Independent Health to provide services. Out-of-network providers may be allowed to bill you for the difference between what we pay 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 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 hospital, 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 a stable condition.
- 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, and 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 can’t give up your protections for these other services if they are a surprise bill. Surprise bills are when you’re at an in-network hospital or ambulatory surgical facility 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: 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 can’t balance bill you and may not ask you to give up your protections not to be balance billed. You will need to sign the NY Surprise Medical Bill Certification Form and send it to your health plan if you receive a surprise bill.
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.
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 deductibles 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, contact the New York State Department of Financial Services at (800) 342-3736 or surprisemedicalbills@dfs.ny.gov. Visit http://www.dfs.ny.gov for information about your rights under state law.
Claim Submission
You may submit a claim to us by mail or email by sending it to the following:
Independent Health
P.O. Box 9066
Buffalo, NY 14231
Attn: Claims Department
memberservice.servicing@independenthealth.com