Surprise medical billing
Health Care & Insurance
Know your rights against surprise medical bills: the No Surprises Act
"Surprise medical bills" are bills that contain higher fees health insurance plans can charge when services are delivered by out-of-network providers rather than in-network providers who have agreed to the prices negotiated by the insurer.
New York has always been a leader in protecting consumers from surprise medical bills. This protection began with the groundbreaking passage of the nation’s first surprise-medical-bill law, as part of the New York Financial Services Law.
Now, New Yorkers have even more safeguards from surprise medical bills under the federal No Surprises Act, which went into effect January 1, 2022.
Under the new law, health care providers and certain facilities cannot bill patients for more than their in-network co-payment, co-insurance, or deductible for certain surprise bills — that is, when patients unexpectedly receive care from out-of-network hospitals, doctors, or other providers that they did not choose, under certain circumstances. Health plans are also required cover these kinds of out-of-network claims and apply only the same in-network cost sharing .
If consumers do receive a bill for these services, they have the right to challenge these charges.
Health care providers and facilities must inform consumers of their rights under the new law by posting a one-page disclosure notice on the facility premises and on their public website. Providers must also give this notice to the consumer when seeking payment, whether from the consumer or their health plan. Health plans are also required to provide consumers the disclosure notice with every explanation of benefits (EOB) that includes a claim for surprise medical bills.
Frequently asked questions
A surprise medical bill is typically a bill for out-of-network medical services that you didn't realize were out of your network.
Many health plans cover their members for both in-network and out-of-network medical care, but at different costs. You can usually save money by visiting facilities and health care providers that are in your health plan network.
But, even when you are careful to try to stay within your plan’s network, you may sometimes unknowingly receive care from an out-of-network health care provider. For example, during a stay at an in-network hospital, you may receive care from a nonparticipating provider, such as an anesthesiologist. In the past, the out-of-network provider could bill you the difference between the billed charge and the amount paid by your health plan. Now, you will no longer be charged these higher amounts for certain surprise bills
The new law applies to the following types of surprise bills:
- Emergency services provided at emergency rooms and freestanding emergency departments: Emergency care includes treatment sought by patients who believe they are experiencing a medical emergency or active labor.
- Non-emergency services provided at in-network facilities: If you receive care from an out-of-network health care provider at an in-network hospital, hospital outpatient department, or ambulatory surgery center, these services are covered under the new law.
- Air ambulance services (but not ground ambulance services, although New York law does provide certain protections against ground ambulance bills): These are covered by the No Surprises Act.
Facilities and health care providers cannot bill you for more than the in-network co-payment, co-insurance, or deductible.
You have appeal rights. You can appeal the determination to your health plan. If your plan upholds its decision, you can appeal to an independent external reviewer. First, review the notice that providers and plans are required to give you, which should summarize the types of services that are covered under the law.
In certain non-emergency circumstances, yes. But you are never required to give up your protections, and you are not required to get out-of-network care. You can always choose a provider or facility in your plan’s network.
You can never be asked to waive your protection from surprise bills for emergency treatment.
You may be asked for written consent to receive treatment from an out-of-network health care provider. The request must be in writing, on a form that notifies you that, if you agree, you may get a bill for the full charges or have to pay out-of-network cost-sharing amounts. If you choose not to consent, the out-of-network provider is not required to treat you, but you may choose to get care from an in-network provider.
However, if you have a fully insured health plan, you can be asked to consent to out-of-network care only if the facility or provider told you of the availability of a participating health care provider at least 72 hours prior to the service. You cannot be asked to consent any closer to the date and time of the procedure.
If you have a self-funded plan — typically an employer-sponsored plan — then the provider or facility can ask you to consent on shorter notice than 72 hours under certain circumstances. If you schedule a service less than 72 hours in advance, the provider or facility cannot ask you to consent any later than the day the appointment is made. For same-day scheduled services, you can be asked up to three hours in advance of the service to consent.
If you refuse to consent, you will be given an in-network provider, at in-network costs. You will not be billed for out-of-network services, and there is no penalty (except you may not get the out-of-network doctor you want).
Yes. You have the right to request a good-faith estimate of the expected charges for non-emergency services, and receive the estimate no later than three business days after the request. In addition, health care providers must give you an estimate, even if you do not request one:
within one business day after an appointment that is scheduled at least three business days in advance
within three business days after an appointment that is scheduled more than 10 business days in advance.
If the amount charged is more than $400 over the estimate, you may dispute the bill if you file your dispute within 120 days of the date on your bill.
No. But, if you have coverage through Medicare, Medicaid, or TRICARE, or receive care through the Indian Health Services or Veterans Health Administration, you’re already protected against surprise medical bills.
Yes. You get the benefit of all consumer protections under both sets of laws. The federal law is only the most basic level (floor) of the protections available to you.
If you believe that you have been improperly charged for a surprise bill by a health care provider, or that a health plan has improperly assessed cost sharing for a surprise bill, you can file a complaint about a surprise medical bill with the Health Care Bureau online, send us a complaint by mail us your complaint about a surprise medical bill, or call the Attorney General's Health Care Helpline at 1-800-428-9071.