No Surprises Act

Also referred to as Balance Billing or Surprise Billing

Avoid surprises in your medical bills:

  • The “No Surprises Act” is federal legislation that addresses billing when patients get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center.
  • Federal law requires all providers to provide a good faith estimate to uninsured individuals or individuals who choose not to have their insurance billed for all medical items and services.
  • New York State law: You are protected from surprise billing under New York State law
  • Your Rights and Protections Against Surprise Medical Bills (printable)

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

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, such
as a copayment, coinsurance, and a deductible. You may have other costs or have to pay the entire
bill if you see a provider or visit a health care facility that is not in your health plan’s network.

“Out-of-network” describes providers and facilities that have not signed a contract with your health
plan. Out-of-network providers may be permitted to bill you for the difference between what your
plan agreed to 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
annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you cannot control who is
involved in your care—including 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.

You are protected from balance billing for:

1. Emergency services

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

You are also protected from balance billing under New York law, including for emergency services in
hospitals, including inpatient care following emergency room treatment.

2. 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 may 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 cannot balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers cannot balance bill you, unless you give written consent and give up your protections.

You are never required to give up your protection from balance billing. You also are not required to get care out-of-network. You can choose a provider or facility in your plan’s network.

You are also protected from balance billing under New York law when you are treated by an out-of-network doctor at a participating hospital or ambulatory surgical center in your health plan’s network.
Additionally, if you have health insurance coverage provided by an insurer or health maintenance organization (HMO) you are protected from balance billing when a participating doctor refers you to
a non-participating provider.

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

  • You are 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 out-of-network providers and facilities directly.
  • Your health plan generally must:
    o Cover emergency services without requiring you to get approval for services in advance
    (prior authorization).
    o Cover emergency services by out-of-network providers.
    o 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.
    o Count any amount you pay for emergency services or out-of-network services toward your
    deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed

Department of Health and Human Services
(877) 696-6775
Your rights under federal law
Department of Health and Human Services

or

New York’s Department of Financial Services 
(800) 342-3736
email:  surprisemedicalbills@dfs.ny.gov
Your rights under New York’s law
Department of Financial Services website

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law, health care providers need to give patients who do not have insurance or who are not using insurance an estimate of the bill for medical items and services.

  • You have the right to receive a Good Faith Estimate for the total
    expected cost of any non-emergency items or services. This includes
    related costs like medical tests, prescription drugs, equipment, and
    hospital fees.
  • Make sure your health care provider gives you a Good Faith Estimate
    in writing at least one business day before your medical service or
    item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
  •  Make sure to save a copy or picture of your Good Faith Estimate.

Questions

OR more information
about your right to a
Good Faith Estimate:

visit www.cms.gov/nosurprises

or call our
EWBC Billing Department
at 585-442-1830

To Receive a Good Faith Estimate from EWBC:

Please have the description or CPC code of the procedure you would like the estimate for

Contact EWBC Billing Department
Call (585) 442-1830
Monday – Friday 7:30 am to 4:30 pm

 

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