When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.
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Consumer Protections
Your Rights and Protections Against Surprise Medical Bills
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays 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 plan’s deductible or annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like 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. Surprise medical bills could cost thousands of dollars depending on the procedure or service.
Emergency services
If you have an emergency medical condition and get emergency services from an out-of-network provider or hospital, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in a stable condition.
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 can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, and intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. If you get other types of services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections. You can’t give up your protections for these other services if they are a surprise bill. Surprise bills are when you’re at an in-network hospital or ambulatory surgical facility and a participating doctor was not available, a non-participating doctor provided services without your knowledge, or unforeseen medical services were provided.
Services referred by your in-network doctor
If you are a member enrolled in a New York insured plan, surprise bills also include when your in-network doctor refers you to an out-of-network provider without your consent (including lab and pathology services). These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. You may need to sign a form (available on the Department of Financial Services’ website at http://www.dfs.ny.gov) for the full balance billing protection to apply.
You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.
- You’re only responsible for paying your share of the cost (like the copayment, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
- Generally, your health plan must:
- Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
- Cover emergency services by out-of-network providers.
- 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.
- Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.
If you are a member enrolled in a New York insured plan and think you’ve been wrongly billed, you can also contact the New York State Department of Financial Services at (800) 342-3736 or visit https://www.dfs.ny.gov/consumers/health_insurance/surprise_medical_bills.
If you are a member enrolled in a self-funded plan, and you think you’ve been wrongly billed, state law protections may not apply, but you may have protections under federal law. Visit https://www.cms.gov/nosurprises for information about your rights under federal law.
Your rights may differ from those described above if you are covered by Medicare or other government programs, or if your plan:
- is non-comprehensive (e.g. dental only, vision only, etc.); or
- does not have a provider network.
What To Do If You Receive a Surprise Bill Or A Bill For Emergency Services
If You Are a Member Enrolled in a Fully-Insured EmblemHealth Plan:
A surprise bill is 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. 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. For a surprise bill, you are only responsible for your in-network copayment, coinsurance or deductible.
What to Do if You Get a Bill for Emergency Services.
If you get a bill for emergency services, contact EmblemHealth at the telephone number on the back of your ID card. You are only responsible for your in-network copayment, coinsurance or deductible.
What to Do if You Get a Surprise Bill.
1. Complete and sign the Surprise Bill Certification Form. You must sign a Surprise Bill Certification Form if:
Your in-network doctor referred you to an out-of-network provider; or
An out-of-network provider treated you at an in-network hospital or ambulatory surgical facility before January 1, 2022. The form is not required for services provided on or after January 1, 2022, but it is recommended.
Surprise Bill Certification Form
2. Send Form and Bill. Send the completed form to EmblemHealth and to the out of network provider and include a copy of the bill(s) you do not think you should pay.
Send the form and bill to EmblemHealth at the address(es) below, and also include a completed claim form or the Explanation of Benefits related to the service(s).
HMO /EPO Plan Types |
PPO/POS Plan Types |
By Mail: EmblemHealth Claims Dept. PO Box 2845 New York, NY 10116-2845 |
By Mail: EmblemHealth Correspondence Department PO Box 2857 New York, NY 10116-2857 |
By Email: HMOEmblemHealthClaim@emblemhealth.com |
By Email: PPOEmblemHealthClaim@emblemhealth.com |
If You Are a Member Enrolled in Self-Funded Coverage or FEHBP:
The Federal No Surprises Act protects you from surprise medical bills from an out-of-network provider in an in-network hospital or ambulatory surgical center for plans issued or renewed on and after January 1, 2022. You are only responsible for your in-network cost-sharing (copayment, coinsurance, or deductible) for a surprise bill. If you receive a surprise bill, contact EmblemHealth at the telephone number on the back of your ID card. You can also visit https://www.cms.gov/nosurprises for information about your rights under federal law.
For plans issued or renewed before January 1, 2022, you may qualify for an independent dispute resolution (IDR) under certain circumstances 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 weren’t given certain required information about your care. For more information, visit the DFS website at https://dfs.ny.gov/consumers/health_insurance/surprise_medical_bills. If you qualify, you must complete an IDR Patient Application and send it to: New York State Department of Financial Services, Consumer Assistance Unit/IDR Process, One Commerce Plaza, Albany, NY 12257.
For Providers:
IDR is available to resolve payment disputes between health plans and providers for emergency services and surprise medical bills.
New York State IDR generally applies to services provided in New York to members enrolled in fully-insured EmblemHealth plans, with certain exceptions.
Federal IDR generally applies to air ambulance services, if covered, services provided outside of New York and to services provided to members enrolled in self-funded coverage or the Federal Employees Health Benefits Plan(s) (FEHBP).
To start the IDR process, take the steps below:
New York State IDR process: Log onto the DFS portal at https://www.dfs.ny.gov/IDR to obtain a tracking number; complete the IDR Provider and Insurer Application; and send the application to the assigned Independent Dispute Resolution entity (IDRE). The IDRE will make a decision within 30 days. IDR must be started within 3 years from the date the plan made the original claim payment.
Federal IDR Process: A provider or plan can start an open negotiation period within 30 business days of the provider’s receipt of either an initial payment or a notice of denial of payment. The open negotiation period lasts 30 business days. At the end of the negotiation period, if the plan and provider are unable to agree on a payment amount, either party can start the federal IDR process within 4 business days after the close of the open negotiation period by sending Notice of IDR Initiation to the other party and logging onto the federal portal at https://nsa-idr.cms.gov/paymentdisputes/s/ to initiate IDR. The IDRE will make a decision within 30 business days after it is selected. See the CMS website at https://www.cms.gov/nosurprises/ for more information about the federal IDR process.
Individuals:
In certain circumstances, IDR may also available to individuals who are uninsured, are self-pay patients or are enrolled in self-funded coverage. For more information, visit the New York State Department of Financial Services website at https://www.dfs.ny.gov/consumers/health_insurance/surprise_medical_bills.
Frequently Asked Questions
Answers to some of the top questions about Consumer Protections.
Emergency services generally refer to the following services provided to treat an emergency condition:
- Medical screening exams that a hospital’s emergency department can perform, including ancillary services routinely used to assess emergency medical conditions, and
- Additional medical exams and treatment required to stabilize a patient.
An emergency condition means a medical or behavioral condition that produces symptoms serious enough to qualify it as an emergency condition. An example is if you have severe pain that you know could result in one or more of the following without getting immediate medical attention:
- Extreme danger to the health of the person experiencing the emergency condition, or a behavioral condition
- Serious impairment to the bodily functions of the affected person
- Serious dysfunction of any bodily organ or part of the affected person
- Serious disfigurement of the affected person.
A surprise bill is a bill you receive for covered services in the following circumstances:
- For services performed by an out-of-network provider at an in-network hospital or ambulatory surgical center, when:
- An in-network provider is unavailable at the time the health care services are performed;
- An out-of-network provider performs services without your knowledge; or
- Unforeseen medical issues or services arise at the time the health care services are performed.
NOTE: A surprise bill is not a bill for health care services when an in-network provider is available and you elected to receive services from an out-of-network provider.
- If you are a member enrolled in a New York fully insured plan, a surprise bill also includes a bill for covered services when you were referred by an in-network doctor to an out-of-network provider without your written consent acknowledging that the referral is to an out-of-network provider and it may result in costs not covered by your health plan.
For a surprise bill, a referral to an out-of-network provider means:
- Covered services are performed by an out-of-network provider in the in-network doctor’s office or practice during the same visit;
- An in-network doctor sends a specimen taken from you in his/her office to an out-of-network laboratory or pathologist; or
- If referrals are required under your health plan, any other covered out-of-network services performed at an in-network doctor’s request.
You will be held harmless for any out-of-network provider charges for the surprise bill that exceed your in-network cost-sharing. The out-of-network provider may only bill you for your in-network cost-sharing. If you are a member enrolled in a fully-insured plan, you can sign a form at Surprise Bill Certification Form to notify your plan and the out-of-network provider that you received a surprise bill.
With limited exceptions, the protections described apply to EmblemHealth Fully Insured, Self-insured and FEHB Program plan comprehensive health plan members whose plans include a provider network feature.
These new rules don’t apply if you are enrolled in one of these plans or circumstances:
- Medicare Supplement Plan
- Medicare Advantage Plan
- Medicaid Managed Care Plan;
- Indian Health Services
- Veteran Affairs Health Care
- TRICARE
- Medicare is your primary coverage (e.g. group health plan retiree benefits that supplement Medicare payments); or
- Other plans and circumstances as may be determined by federal and/or New York law and regulations.
Estimating Out-of-Network Care Costs
EmblemHealth has Cost Calculators you can use to estimate your out-of-pocket costs for specific services from an out-of-network doctor. You can access these calculators through your secure online member account, myEmblemHealth. To get started, sign in to or register for your account.
It depends whether the doctor is inside or outside the provider network for your health plan.
- Seeing an in-network doctor? Use the Treatment Cost Calculator.
- Seeing an out-of-network doctor? Use the Fair Health Calculator.
Use our Find a Doctor tool or call the Customer Service number on the back of your member ID card. Be sure to confirm the doctor participates in your plan’s provider network by asking the doctor’s office when making an appointment.
The steps for calculating costs may differ depending on your plan type. The “Cost Calculator” section of your secure online member account will guide you through the process you should follow based on your plan type. Please note the following, which may affect your costs:
- HMO and EPO plans: If you have an HMO or EPO plan, then your plan generally does not cover out-of-network benefits, except for emergency services.
- PPO and POS plans: If you have a PPO or POS plan, then your plan generally does provide benefits for most covered services received from out-of-network providers. The terms and conditions of out-of-network coverage vary depending on the specific plan you have.
See an Out of Network Reimbursement Example
To use the Cost Calculators, sign in to or register for your secure online member account and go to “Cost Calculators.”
Note: The EmblemHealth allowance will generally not reflect any applicable cost-sharing (i.e., copayment, deductible and/or coinsurance), which you must also pay toward the service(s) and will reduce the amount of the allowance actually payable by EmblemHealth. See your member contract or certificate of coverage for the cost-sharing that applies under your plan. Benefits will be subject to all terms, conditions, limitations and exclusions set forth in your plan. Benefit estimates from the calculators are not a guarantee. The actual payment will depend on a number of factors, including, for example, the services you receive, the amount billed by your doctor or other provider, the actual procedure codes submitted and your eligibility for benefits at the time you receive services.
Allowance: What a plan will pay for covered out-of-network services before cost-sharing is applied.
Cost-Sharing: The portion of the plan's schedule or allowance that plan members pay to use covered health services. There are three possible types of cost-sharing: copay, coinsurance and deductible. The amount of these costs depends on your specific health plan. For out-of-network benefits, cost-sharing does not include the difference between the EmblemHealth allowance and the provider's charges, which you are also responsible to pay (in addition to cost-sharing).
Explanation of Benefits (EOB): A summary of our payment decision(s) relating to a claim for health care services.
In-Network Provider: A doctor or other health care provider, or a health care facility, that participates in your health plan's provider network.
Network: Group of doctors, hospitals and other health care providers with whom a health insurer contracts to deliver medical services to its plan members.
Out-of-Network Provider: A doctor or other health care provider, or a health care facility, who does not participate in your health plan's provider network.
