Consumer Protection Under The Federal No Surprises Act

The Federal No Surprises Act protects you from surprise medical bills and makes it easier for you to understand the costs of health care services before you get a service. You may receive a surprise bill when you see a health care provider that is not in your health plan’s network (an out-of-network provider). Under these new protections, you only have to pay your in-network copayment, coinsurance, or deductible for emergency services or when you receive a surprise bill. Health care providers should not bill you for any additional amounts. The new protections started January 1, 2022.

Protections For People Who Have Health Insurance

Most New Yorkers already have protection from surprise medical bills if they or their employer bought health insurance in New York. If you or your employer purchased health insurance outside of New York, you should speak to your insurer about protections specific to that state. Also, you may have different protections if your employer self-funds its employees’ health insurance.

Check your health plan ID card. If you don’t see the phrase “fully insured coverage,” New York protections probably do not apply to your coverage. See section below titled, “Protections for Consumers Who Have Self-Funded Employer Coverage.”

Below is more information on your New York protections and how some of your protections may have changed because of the No Surprises Act.

Protections from Bills for Emergency Services and Surprise Bills

You are protected from surprise bills when you are treated by an out-of-network doctor at an in-network hospital or ambulatory surgical center. These protections are increasing and will now include all providers, and not just doctors.

You are also protected from surprise bills when an in-network doctor refers you to an out-of-network provider. This includes services you get when you are in your doctor’s office, when your doctor sends a sample taken from you to an out-of-network lab or pathologist, and for other health care services when a referral is required and you received a referral from your in-network doctor.

You are covered for emergency services in a hospital if you have a medical or behavioral condition and you need immediate medical treatment.  You are protected from bills for out-of-network emergency services in a hospital, including inpatient care following emergency room treatment until you are discharged from the hospital. These protections are increasing and will now include all providers, and not just doctors, for emergency services in hospitals.

For these bills, you are only responsible for your in-network cost-sharing. For more information, visit the DFS Surprise Medical Bills webpage.

Protections from Air Ambulance Bills

If air ambulance services are covered under your health plan, you are only responsible for your in-network cost-sharing, even if the service was from an out-of-network provider.

The air ambulance provider and your health plan can negotiate the total payment amount to the provider. If the provider and your health plan don’t agree on a payment amount, the health plan or provider may send a dispute to CMS under the Federal independent dispute resolution process. You don’t need to do anything as part of this process. For more information, visit the CMS No Surprises Act website.

If your health plan denies coverage for air ambulance services as not medically necessary, you have the right to file an external appeal with the Department of Financial Services.  

If you think you have been wrongly denied coverage for air ambulance services by your health plan for other reasons or were billed for more than your in-network cost-sharing, you can file a complaint with DFS.

Disclosure on Health Insurance ID Cards

Currently, your health plan identification card (ID card) must include the following information:

  • Your name, your dependents’ names, and identification numbers;
  • Copayment or coinsurance amounts (if you have them) for in-network providers for: 
    • primary care office visits;
    • specialist office visits;
    • urgent care;
    • emergency room visits; and
    • prescription drugs for a 30-day supply;
  • A telephone number where you can get consumer assistance;
  • The name and website of the health plan providing the coverage;
  • The name of your coverage and type (e.g., POS, HMO, EPO, PPO, or fee-for-service);
  • The name of the health care provider network(s) (if there is one);
  • The name of the prescription drug formulary (if there is one); and
  • The phrase “fully insured coverage” (which means your coverage follows New York law).

Beginning in 2022, new information will be added to your ID card.  Your ID card will also include:

  • Deductibles (if you have them); and
  • Out-of-pocket maximum limits.

Provider Directory Updates

Your health plan must have a provider directory that lists in-network providers (if your health plan uses a network of providers).  The provider directory must be available on your health plan’s website and you can also get a printed copy from your health plan.  The provider directory has the following information:

  • A listing, by specialty (if applicable), of the name, address, and telephone number of all in-network providers (including facilities);
  • Whether the provider is accepting new patients;
  • For doctors, the board certification, languages spoken, and any affiliations with in-network hospitals; and   
  • For mental health or substance use disorder services providers, any affiliations with in-network facilities authorized by the Office of Mental Health or the Office of Addiction Services and Supports and any restrictions regarding the availability of the provider’s services.  For example, the directory may tell you if the provider only treats adults or children or a specific mental health condition.

Your health plan must update the online provider directory within 15 days to add new in-network providers, remove providers that are no longer in-network, or to change a physician’s hospital affiliation.  Your health plan must update the hard copy of the provider directory every year.

Protections from Provider Directory Misinformation

If you get provider directory misinformation from your health plan, you will pay no more than your in-network cost-sharing for those services.

Provider directory misinformation happens when:

  • An out-of-network provider is wrongly listed as an in-network provider in your health plan’s online provider directory;
  • An out-of-network provider is wrongly listed as an in-network provider in your health plan’s hard copy provider directory and the directory was wrong as of the date it was published;
  • Your health plan tells you in writing that a provider is in-network when the provider is not in-network when you ask for this information over the telephone; or
  • Your health plan doesn’t tell you the network status of a particular provider in writing within one business day of your request for this information by telephone.

If you got provider directory misinformation, your health care provider must give you a refund if you paid more than your in-network cost-sharing.

Continuing Care When Your Provider Leaves the Network

If your provider (including a facility) leaves your health plan’s network while you are in an ongoing course of treatment, your health plan must cover a period of transitional care.  You can continue treatment with that provider:

  • For up to 90 days from when your provider leaves the network; or
  • If you’re pregnant, through your pregnancy, including any post-partum care.

If your provider continues to treat you during your transitional care period, the provider must accept payment from your health plan.  You will only pay your in-network cost-sharing during that time.

Understanding Your Costs in Advance

Health care providers will be required to give a good faith estimate of the cost of the services to your health plan.  Your health plan will use the good faith estimate to prepare an “advanced explanation of benefits” for you.

The advanced explanation of benefits will tell you:

  • Cost information from your provider;
  • If the provider is in-network or out-of-network for the service you are getting;
  • A good faith estimate of your cost-sharing amount;
  • A good faith estimate of the amount your health plan will pay; and
  • An estimate of the amounts you’ve already paid toward your deductible or out-of-pocket maximum.

For more information about when these requirements will go into effect, check the CMS No Surprises Act website.

Price Comparison Tool

Health plans must help you compare prices for services.  Health plans must have a price comparison tool on their websites and give you the information if you ask for it by telephone.  The price comparison tool will help you compare the cost-sharing you would need to pay for a service from different providers.  The tool should be available to you in 2023 for some services.

Agent/Broker Fees for Individual Health Insurance

Before you enroll in individual health insurance coverage, you should get information from your health plan that tells you the amount that an agent or broker will be paid for helping you with your plan selection and enrollment.  You should get this information before you make your choice, and it should be on any documents you get confirming your enrollment.  This information may help you decide if the amount to be paid to the agent or broker is fair for the services provided.

Protections For Consumers Who Have Self-Funded Employer Coverage

The Federal protections from surprise medical bills apply if your employer self-funds your coverage, but state protections don’t apply to self-funded coverage.  Check your ID card.  If you don’t see the phrase “fully insured coverage,” your coverage is probably self-funded.  For more information about the Federal consumer protections, visit the CMS No Surprises Act website.

Protections For Consumers Who Don’t Have Health Insurance

Good Faith Estimate for Uninsured or Self-Pay Patients

If you are uninsured, or you are insured but you don’t plan to file a claim with your health plan, health care providers must give you a good faith estimate of what their expected charges will be before you get the services.

Providers must give you the good faith estimate:

  • For services scheduled at least 3 business days ahead of time, within 1 business day of scheduling the service;
  • For services scheduled at least 10 business days ahead of time, within 3 business days of scheduling the service; or
  • When you ask for the good faith estimate, within 3 business days of you asking for the estimate.

The good faith estimate will include:

  • A description of the service you will be getting;
  • A list of other services that are reasonably expected to be provided with the service you are getting;
  • The diagnosis and expected service codes; and
  • The expected charges for the services.

For more information about good faith estimates, visit the CMS No Surprises Act website.

Patient-Provider Dispute Resolution Process

If you are billed for an amount that is at least $400 more than the total amount on the good faith estimate you got from your health care provider, you (or your authorized representative) may dispute the charges in the Federal patient-provider dispute resolution process.  You have to ask for the review within 120 days of getting the bill.  An independent reviewer will look at the good faith estimate, the bill, and information from the provider to decide the amount, if any, that you have to pay for each service.

You can use the patient-provider dispute resolution process starting in 2022 for billing disputes with the provider that scheduled the service for you.  Later, the process will allow you to dispute bills from other providers that gave you other related services.

For more information about the patient-provider dispute resolution process, visit the CMS No Surprises Act website.