Know Your Rights Against Surprise Medical Bills: The No Surprises Act

New York has always been a leader in protecting its consumers from surprise medical bills beginning 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 will have even more safeguards from surprise medical bills under the federal No Surprises Act, which went into effect January 1, 2022.

Surprise medical bills refer to the higher fees that 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.

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 out-of-network bills—that is, where patients unexpectedly received care from out-of-network hospitals, doctors, or other providers that they did not choose, under certain circumstances. Health plans will also be required to cover these kinds of out-of-network claims and apply the same in-network cost sharing only.

If consumers do receive a bill for these services, they have the right 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 site and on their public website. Providers must also give this notice to each consumer when they seek 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.

1. What is a surprise medical bill?

2. How much can I be charged for a surprise bill?

3. What can I do if I think my health plan improperly applied out-of-network cost-sharing, and I received a provider bill?

4. Can my health care provider ask me to waive my rights?

5. My provider asked me to consent to out-of-network care, what does that mean?

6. What if I refuse to consent to out-of-network care when asked by my provider?

7. I'm uninsured, are there any protections for me?

8. I have Medicaid or Medicare, am I covered by the new law?

9. I thought New York already had a surprise billing law, are those provisions still in place?

10. What if I have additional questions about surprise bills?

A surprise medical bill is typically a bill for out-of-network medical services that a consumer didn’t realize were out-of-network.

Many health plans cover their members for both in-network and out-of-network medical care, but at different costs. Consumers can usually save money by visiting facilities and health care providers that are in their health plan network. 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, a consumer who visits an in-network hospital may receive care from a nonparticipating provider, such as an anesthesiologist. In the past, the out-of-network provider could bill the consumer the difference between the billed charge and the amount paid by the consumer’s health plan. Now, consumers will no longer be charged these higher amounts for certain 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).

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. You should 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 aren’t 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 only be asked to consent to out-of-network care 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—which is 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 (3) 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 won’t be billed out-of-network, 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 (3) business days after the request. In addition, health care providers must give you an estimate -- even if you do not request one -- within 1 business day after an appointment that is scheduled at least three (3) business days in advance, or within 3 business days after an appointment that is scheduled more than ten (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 “floor” of 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 may file a complaint with the Health Care Bureau online, by mail, or call the Attorney General's Health Care Helpline at 1-800-428-9071.