Surprise Medical Bills and Emergency Services
Consumers in New York are protected from surprise bills when treated by an out-of-network provider at a participating hospital or ambulatory surgical center in their health plan’s network. Additionally, consumers with health insurance coverage provided by an insurer or HMO are protected from surprise bills when a participating doctor refers them to a non-participating provider. Consumers in New York are also protected from bills for emergency services in hospitals, including inpatient care following emergency room treatment.
- Learn more about Consumer Protections Under the No Surprises Act
The following information explains what you need to know about these important protections if:
- you have coverage with an HMO or insurer subject to New York law
- you are uninsured or your employer or union provides self-insured coverage that is not subject to New York law
- you are a health care provider.
Information Your Doctor and Other Health Care Professionals Must Give You
Information Your Hospital Must Give You
How to Protect Yourself from a Surprise Medical Bill
If You Have Health Insurance Coverage Subject To NY Law – (your health insurance ID card says “fully insured”)
Surprise bills happen when an out-of-network provider treats you at an in-network hospital or ambulatory surgical center OR you are referred by an in-network doctor to an out-of-network provider. (In-network means in your health plan’s network.) You only have to pay your in-network cost-sharing for a surprise bill.
It’s A Surprise Bill At An In-Network Hospital or Ambulatory Surgical Center if an Out-of-Network Provider Treats You and:
- An in-network provider was not available; OR
- An out-of-network provider provided services without your knowledge; OR
- Unforeseen medical services were provided when you received health care services.
It is NOT a surprise bill if you chose to receive services from an out-of-network provider instead of from an available in-network provider before you got to the hospital or ambulatory surgical center.
Beginning January 1, 2022, the following services will usually be a surprise bill when provided by an out-of-network provider in a hospital or ambulatory surgical center: emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services.
If your health care services were before January 1, 2022, you are only protected from a surprise bill if you were treated by an out-of-network physician (and not other health care providers) at an in-network hospital or ambulatory surgical center.
It’s a Surprise Bill When Your In-Network Doctor Refers You to an Out-of-Network Provider if:
- You did not sign a written consent that you knew the services were out-of-network and would not be covered by your health plan; AND
- During a visit with your participating doctor, a non-participating provider treats you; OR
- Your in-network doctor takes a specimen from you in the office (for example, blood) and sends it to an out-of-network laboratory or pathologist; OR
- For any other health care services when referrals are required under your plan.
If You Get a Surprise Bill Because An Out-of-Network Provider Treats You At An In-Network Hospital Or Ambulatory Surgical Center OR Your Doctor Refers You To An Out-of-Network Provider:
- You only have to pay your in-network cost-sharing.
- If an out-of-network provider bills you for any amount over your in-network cost-sharing (copayment, coinsurance, or deductible) this is called balance-billing.
- If your doctor referred you to an out-of-network provider, you MUST send a Surprise Bill Certification Form to your health plan and your provider to make sure that they know you received a Surprise Bill and that you must be protected from balance billing.
- If an out-of-network provider treats you at an in-network hospital or ambulatory surgical facility, you MUST send a Surprise Bill Certification Form to your health plan and your provider if you received the health care services before January 1, 2022 to make sure that they know you received a Surprise Bill and that you must be protected from balance billing. The form is not required for services provided after January 1, 2022 at an in-network hospital or ambulatory surgical facility, but it is recommended.
- You may also file a complaint with DFS.
If You Have Employer/Union Self-Funded Coverage (your health insurance ID card says “self-funded” or does not say “fully insured”)
The Federal No Surprises Act protections from surprise medical bills from an out-of-network provider in an in-network hospital or ambulatory surgical center apply if your employer or union self-funds your coverage for plans issued or renewed on and after January 1, 2022.
You are only responsible for paying your in-network cost-sharing (copayment, coinsurance, or deductible) for a surprise bill.
For more information about the Federal consumer protections, visit the CMS No Surprises Act website.
For plans issued or renewed before January 1, 2022, you may qualify for an independent dispute resolution (IDR) through New York State by submitting an IDR application to dispute the bill. To be eligible, services must be provided by a doctor at a hospital or ambulatory surgical center and you aren’t given all the required information about your care. See Information Your Doctor and Other Health Care Professionals Must Give You and Information Your Hospital Must Give You for a list of the information that must be provided to you.
Application
Complete an IDR Patient Application and send it to NYS Department of Financial Services, Consumer Assistance Unit/IDR Process, One Commerce Plaza, Albany, NY 12257.
How to Protect Yourself If You Are Uninsured
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 health care 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 for Good Faith Estimates
If you are billed for an amount that is at least $400 more than the 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 Federal 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 related services.
For more information about the patient-provider dispute resolution process, visit the CMS No Surprises Act website.
New York State Patient-Provider Dispute Resolution Process If You Don’t Get a Good Faith Estimate
If your provider doesn’t give you a good faith estimate and you feel the charge is unreasonable, you may qualify for an independent dispute resolution (IDR) through New York State by submitting an IDR application to dispute the bill. To be eligible, services must be provided by a doctor at a hospital or ambulatory surgical center and you aren’t given all the required information about your care. See Information Your Doctor and Other Health Care Professionals Must Give You and Information Your Hospital Must Give You for a list of the information that must be provided to you.
Complete an IDR Patient Application and send it to NYS Department of Financial Services, Consumer Assistance Unit/IDR Process, One Commerce Plaza, Albany, NY 12257.
Information Your Doctor And Other Health Care Professionals Must Give You
Your doctor and other health care professionals, including a group practice of providers, a diagnostic and treatment center, and a health center must give patients and prospective patients the following information:
- Health Plan Networks. The names of health plans in which your provider is in-network. This must be given to you in writing or through a website before you receive non-emergency services and verbally when you schedule an appointment.
- Hospital Affiliations. The hospitals that your provider is affiliated with or that could admit you. This must be given to you in writing or through a website before you receive non-emergency services and verbally when you schedule an appointment.
- Cost of Services. If your provider is not in-network with your health plan, your provider must tell you the estimated amount your provider will bill you for services if you ask.
- Providers Scheduled by Your Doctor. If your doctor schedules anesthesiology, laboratory, pathology, radiology or assistant surgeon services to be provided in your doctor's office or refers you for these services, your doctor must tell you:
- The provider's name, if your doctor schedules a certain provider in a practice.
- The name of the provider's practice.
- The provider's address.
- The provider's telephone number.
- When Your Doctor Schedules Your Hospital Services. If your doctor schedules any other doctors to treat you in a hospital your doctor must tell you:
Information Your Hospital Must Give You
Hospitals must post on their websites:
- Charges. A list of what they charge (or how you can get this information if a list of charges is not posted).
- Health Plan Networks. The health plans in which they are in-network.
- Information About Charges Of Doctors In The Hospital:
- Services provided to you by doctors in the hospital are not included in the hospital's charges.
- Doctors who provide services in the hospital may or may not be in the same health plan networks as the hospital.
- You should ask the doctor arranging your hospital services if the doctor is in your health plan's network.
- Doctors That Could Provide Services to You. The name, address, and telephone number of the doctor groups that the hospital has contracted with to provide services (such as anesthesiology, pathology or radiology) and instructions how to contact these groups to determine if they are in your health plan’s network.
- Doctors Employed By The Hospital. The name, address, and telephone number of doctors employed by the hospital to treat patients and the health care plans where they are in-network.
Hospitals must, in registration or admission materials that they give you before non-emergency hospital services:
- Tell You To Contact Your Doctor. Tell you to check with the doctor arranging your hospital services to determine:
- The name, practice name, address, and telephone number of any other doctor who will be arranged by your doctor to treat you.
- Whether doctors who are employed or contracted by the hospital for services, such as anesthesiology, pathology and radiology, are expected to treat you.
- How to Tell If Your Doctor is In-Network With Your Health Plan. Tell you how to find out whether doctors who are employees of the hospital (such as for anesthesiology, pathology and radiology) are in-network with your health plan.
When Receiving Emergency Services
If You Have Health Insurance Coverage Subject to NY Law (your health insurance ID card says “fully insured”)
You only have to pay your in-network cost-sharing (copayment, coinsurance, and deductible) for bills for out-of-network emergency services in a hospital.
- This includes bills from doctors, the hospital*, and beginning in January 2022, any other providers who treat you.
- This includes inpatient services if you are admitted to the hospital after your emergency room visit.
- Your provider may only bill you for your in-network cost-sharing (copayment, coinsurance, or deductible) for emergency services, including inpatient services which follow an emergency room visit.
- Let your health plan know if you receive a bill from an out-of-network provider for emergency services.
- You may also file a complaint with DFS.
Emergency Services - How To Protect Yourself If You Have Employer/Union Self-Funded Coverage (your health insurance ID card says “self-funded” or does not say “fully insured”)
The Federal No Surprises Act protections for bills for out-of-network emergency services apply if your employer or union self-funds your coverage for plans issued or renewed on and after January 1, 2022. This includes inpatient care following emergency room treatment (post-stabilization services).
You are only responsible for paying your in-network cost-sharing (copayment, coinsurance, or deductible) for emergency services.
For more information about the Federal consumer protections, visit the CMS No Surprises Act website.
For plans issued before January 1, 2022, you may qualify for an independent dispute resolution (IDR) through New York State by submitting an IDR application to dispute the bill. You will have to pay the fee for the IDR (up to $395) if your provider’s bill is upheld unless your household income is below 250% of the Federal Poverty Level. Complete an IDR Patient Application and send it to NYS Department of Financial Services, Consumer Assistance Unit/IDR Process, One Commerce Plaza, Albany, NY 12257.
Emergency Services - How To Protect Yourself If You Are Uninsured
If you are uninsured, you may file a dispute through the New York State independent dispute resolution (IDR) process if you receive a bill for emergency services in New York that you believe is excessive. You will have to pay the fee for the IDR (up to $395) if your provider’s bill is upheld unless your household income is below 250% of the Federal Poverty Level.
Complete an IDR Patient Application and send it to NYS Department of Financial Services, Consumer Assistance Unit/IDR Process, One Commerce Plaza, Albany, NY 12257.
Surprise Medical Bills - What Health Care Providers Need To Know If A Patient Has Insurance Coverage Subject To NY Law (coverage that is not self-funded)
You may only bill your patient for their in-network cost-sharing (copayment, coinsurance, or deductible) for a Surprise Bill in a Hospital or Ambulatory Surgical Center or for a Surprise Bill When Your Patient Received A Referral. Health plans must pay out-of-network providers directly for a surprise bill.
A Bill For Services In a Hospital or Ambulatory Surgical Center is a Surprise Bill If:
- Your patient receives services from an out-of-network provider* at an in-network hospital or ambulatory surgical center and: (1) an in-network provider was not available; or (2) an out-of-network provider provided services without your patient's knowledge; or (3) unforeseen medical circumstances arose at the time the health care services were provided.
- It is NOT a surprise bill when an in-network provider was available and the patient elected to obtain services from an out-of-network provider.
- Providers must give patients all notices required under the No Surprises Act and Public Health Law regarding scheduled services.
- Patients must have a meaningful opportunity to choose an in-network provider in advance of the services (at least 72 hours in advance of the services). Notice done on the day of the services does not give the patient a meaningful opportunity to choose an in-network provider.
- It will not be surprise bill when the patient signs the standard written notice and consent form. However, surprise bill protections will typically apply to emergency medicine, anesthesiology, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, and intensivist services (even if the patient receives written notice that you are an out-of-network provider and gives written consent.)
- It will not be a surprise bill if the out-of-network service was preauthorized in advance and the patient received notice that the service was out-of-network and other disclosures required by the Insurance Law, like the amount the health plan would pay for the service.
(*If health care services were before January 1, 2022, the surprise bill protections only apply to the services of out-of-network physicians (and not other health care providers) at an in-network hospital or ambulatory surgical center.)
A Bill For Services Referred By An In-Network Doctor To An Out-of-Network Provider Is A Surprise Bill If:
- Your patient did not sign a written consent acknowledging that the services would be out-of-network and would result in costs not covered by the patient's health plan AND (1) During a visit with an in-network doctor, an out-of-network provider treats the patient; or (2) The patient's in-network doctor takes a specimen from the patient in the office (for example, blood) and sends it to an out-of-network laboratory or pathologist; or (3) For any other health care services when referrals are required under the patient's plan.
Surprise Bill Certification Form. An out-of-network provider may ask their patient to sign a Surprise Bill Certification Form at the time that services are provided. An out-of-network provider must send a copy to the patient’s health plan. For services at an in-network hospital or ambulatory surgical center, an out-of-network provider can sign the Surprise Bill Certification Form and send it to the health plan with the claim for dates of service on and after January 1, 2022.
Disclosure of Balance Billing Protections. Providers must make publicly available (post in the provider’s public location), post on their public websites, and provide to patients, a one-page notice in clear and understandable language containing information on:
- The Federal requirements and prohibitions relating to prohibitions on balance billing for emergency services and surprise bills;
- New York requirements prohibiting balancing billing for emergency services and surprise bills; and
- Information on how to contact New York and Federal agencies in case an individual believes that a provider has violated any state or federal prohibitions on balance billing for emergency services and surprise bills.
Model Disclosure Form. Department of Financial Services has a model disclosure form that providers can use that will satisfy these disclosure requirements.
If You Are an Insurer or Provider with a Dispute
Providers or insurers submitting a dispute involving a surprise bill or bill for emergency services for an insured patient must log onto the DFS portal to obtain a case number.
If it is your first time using the DFS Portal you will need to create a Portal account, then use the Ask for Apps tab to request access to NY IDR. Once you submit the IDR, you will receive an IDR case number:
Once you have the case number:
- fill out the IDR Provider and Insurer Application AND
- send the application to the assigned Independent Dispute Resolution Entity.
Surprise Medical Bills - What Health Care Providers Need To Know If A Patient Is Uninsured
If your patient is uninsured, a bill will be a surprise bill if: Services are provided by a doctor at a hospital or ambulatory surgical center and the patient is not given all the required information about their care. See Information Your Doctor and Other Health Care Professionals Must Give You and Information Your Hospital Must Give You for a list of the information that must be provided to patients. In such cases, your patient may dispute the amount of the bill through the New York State independent dispute resolution process.
Surprise Medical Bills - What Health Care Providers Need To Know If A Patient Has Employer/Union Self-Funded Coverage
The Federal No Surprises Act protections from surprise medical bills from an out-of-network provider in an in-network hospital or ambulatory surgical center apply if your patient has employer or union self-funded coverage for plans issued or renewed on and after January 1, 2022. Your patient is only responsible for paying their in-network cost-sharing (copayment, coinsurance, or deductible) for a surprise bill.
For more information about the Federal IDR process for surprise bills visit the CMS No Surprises Act website.
For plans issued or renewed before January 1, 2022, your patient may qualify for an independent dispute resolution (IDR) through New York State by submitting an IDR application to dispute the bill. A bill will be a surprise bill if services are provided by a doctor at a hospital or ambulatory surgical center and the patient is not given all the required information about their care. See Information Your Doctor and Other Health Care Professionals Must Give You and Information Your Hospital Must Give You for a list of the information that must be provided to patients.
Emergency Services Bills - What Health Care Providers Need To Know If A Patient Has Health Insurance Coverage Subject To NY Law (not self-funded)
When You Bill A Patient. If you are an out-of-network provider that provided emergency services in a hospital, including inpatient services that follow an emergency room visit, you are prohibited from billing a patient for any amount over their in-network cost-sharing (copayment, coinsurance, or deductible).
Payment for emergency services. Health plans are required to pay out-of-network providers directly for emergency services.
Independent Dispute Resolution (IDR). Health care providers (including hospitals) that are not in a health plan’s network may dispute the amount they are paid by the health plan for emergency services in a hospital, including payment for inpatient services that follow an emergency room visit, through the New York State independent dispute resolution process.
If You Are an Insurer or Provider with a Dispute
Providers or insurers submitting a dispute involving a surprise bill or bill for emergency services for an insured patient must log onto the DFS portal to obtain a case number.
If it is your first time using the DFS Portal you will need to create a Portal account, then use the Ask for Apps tab to request access to NY IDR. Once you submit the IDR, you will receive an IDR case number:
Once you have the case number:
- fill out the IDR Provider and Insurer Application AND
- send the application to the assigned Independent Dispute Resolution Entity.
Emergency Services Bills - What Health Care Providers Need To Know If A Patient Has Employer/Union Self-Funded Coverage
The Federal No Surprises Act protections from bills for emergency services apply if your patient has employer or union self-funded coverage for plans issued on and after January 1, 2022. Your patient is only responsible for paying their in-network cost-sharing for emergency services.
For more information about the Federal IDR process for emergency services visit the CMS No Surprises Act website.
For plans issued or renewed before January 1, 2022, your patient may qualify for an independent dispute resolution (IDR) through New York State by submitting an IDR application to dispute the bill.
Emergency Services Bills - What Health Care Providers Need to Know if a Patient Is Uninsured
Your patient may dispute the amount of the bill through the New York State independent dispute resolution process.
Health Care Providers - How to Submit A Dispute Through the New York Independent Dispute Resolution (IDR) Process
Providers or insurers submitting a dispute involving a surprise bill or bill for emergency services for an insured patient must log onto the DFS portal to obtain a case number.
If it is your first time using the DFS Portal you will need to create a Portal account, then use the Ask for Apps tab to request access to NY IDR. Once you submit the IDR, you will receive an IDR case number:
Once you have the case number:
- fill out the IDR Provider and Insurer Application AND
- send the application to the assigned Independent Dispute Resolution Entity.
Review Of Disputes By Independent Dispute Resolution Entity (IDRE)
IDR Entity Reviews. Disputes are reviewed by independent dispute resolution entities (IDREs). Decisions will be made by a reviewer with training and experience in health care billing and reimbursement in consultation with a licensed physician in active practice in the same or similar specialty as the physician providing the service that is the subject of the dispute.
30 Day Timeframe. The IDRE will make a determination within 30 days of receipt of the dispute. Parties to the dispute must submit all necessary information with their IDR application and immediately when contacted by the IDRE, or the information will not be considered.
IDRE Determines The Fee. For disputes involving health plans, the IDRE chooses either the out-of-network provider’s bill or the health plan’s payment. For disputes submitted by uninsured patients, the IDRE determines the fee.
IDRE Considers These Factors When Making a Determination:
- Whether there is a gross disparity between the fee charged by the provider and (1) fees paid to the provider for the same services provided to other patients in health care plans in which the provider is out-of-network, and (2) the fees paid by the health plan to reimburse similarly qualified out-of-network providers for the same services in the same region;
- The provider's training, education, experience, and usual charge for comparable services when the provider does not participate with the patient's health plan;
- In the case of a hospital, the teaching status, scope of services, and case mix;
- The circumstances and complexity of the case;
- Patient characteristics; and
- For physician services, the usual and customary cost of the service.
IDRE may direct a good faith negotiation for settlement. In cases when settlement is likely, or if the health plan's payment and the provider's fee are unreasonably far apart, the IDRE may direct the parties to negotiate.
Review is Binding. The review is binding but admissible in court.
Payment For Independent Dispute Resolution (IDR)
Disputes Between a Provider and a Health Plan, Involving an Insured Patient.
- Provider pays the cost of the dispute resolution when the IDRE determines that the health plan's payment is reasonable.
- Health plan pays the cost of the dispute resolution when the IDRE determines that the provider's fee is reasonable.
- Provider and the health plan share the prorated cost when there is a settlement.
- There may be a minimal fee to the provider or health plan submitting the dispute if the dispute is found ineligible or incomplete.
Disputes involving an Uninsured Patient.
- The provider pays the cost of the dispute resolution when the IDRE determines that the provider’s fee is not reasonable.
- The patient pays the cost of the dispute resolution when the IDRE determines that provider’s fee is reasonable, unless it would pose a hardship to the patient. "Hardship" means a household income below 250% of the Federal Poverty Level.
Questions About IDR
If you have questions about IDR, or need help completing an application, call (800) 342-3736 or email [email protected]. Where applicable, please indicate the date(s) of service in your inquiry as different laws and processes may apply depending on when you received the services.
Questions About Becoming a Certified IDRE
For further information on how to become a certified Independent Dispute Resolution Entity (“IDRE”) please visit our IDRE information page or email [email protected].