New amendments to the NY Insurance Law: out-of-network benefits and services – Surprise Bills
by Anthem Blue Cross Blue Shield
April 14, 2015
“New amendments to the New York Insurance Law went into effect April 1, 2015. Included in these amendments are new consumer rights regarding “surprise bills” and access to out-of-network benefits, as well as increased information for insureds about out-of-pocket costs for out-of-network services.
The law includes key elements on “surprise bills” that may impact members including:
- Updated protections from “surprise bills.” The concept of a “surprise bill” has been introduced for services by non-participating physicians and other providers, like labs. Surprise bills may occur if:
- A member got a procedure at a hospital or surgery center that is in network. But while they were there, they also got care from a doctor who doesn’t participate in their network and:
- A participating doctor wasn’t available;
- The member didn’t know he or she was getting care from a non-participating doctor; or
- An unexpected medical need required the member to get care from a non-participating doctor.
- A member was referred by a participating doctor to an out-of-network provider and the member didn’t sign a consent form to show they understood there may be additional costs. For this purpose, a referral occurs when:
- The member gets care from a non-participating provider in the same office, during a visit to the participating doctor.
- The participating doctor takes a specimen, such as a tissue sample, that’s sent to a non-participating lab or pathologist.
- The member is referred to a non-participating provider by a participating doctor when referrals are required under the plan.
- A member got a procedure at a hospital or surgery center that is in network. But while they were there, they also got care from a doctor who doesn’t participate in their network and:
If a member receives services that result in a surprise bill, the non-participating provider will be required to hold the insured member harmless if the member completes a new assignment of benefits form. The provider can then submit the claim to an independent dispute resolution entity (IDRE).
Other provisions of the law include:
- Expanded rights for reimbursement of emergency services to now include all types of plans (previously applied to HMO plans only). When a member receives emergency services from a non-participating provider, their out-of-pocket expenses can be no more than what would have applied to in-network services. The member is held harmless for charges beyond the in-network cost share amount.
- New cost disclosure requirements for providers and carriers when going out-of-network. Providers must now tell members whether they are in or out-of-network for a given plan, and their hospital affiliations, before they render non-emergency services or when an appointment is scheduled. The out-of-network provider must provide the estimated amount they will bill for non-emergency services upon request. For inpatient and scheduled outpatient hospital services, the facility must now identify any additional providers that will be rendering care to that patient.
Members will also begin to see expanded information from us regarding costs, out-of-network reimbursement, and dispute resolution rights associated with out-of-network care, as well as when services are considered out-of-network. This language will now appear on EOBs, the notices and updates section of empireblue.com, and UM authorization and denial letters. Please note, the dispute resolution processes differ for disputes over ER bills versus those over surprise bills.
There are other elements to the new amendments that went into effect on April 1. This article contains some highlights. For more information, you can read about them at the Department of Financial Services (DFS) website. Always consult the Evidence of Coverage for complete coverage details and conditions.
This article applies to:
- New York
- Small Group, Large Group, and Individual (under 65)“