Billing Protections

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Your Rights and Protections Against Surprise Medical Bills

When you receive emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you’re protected from balance billing. In these situations, you’ll only be responsible for your plan’s standard costs, such as your copayment, coinsurance, or deductible. At ME Plastic Surgery, we’re dedicated to delivering outstanding care with clear, upfront communication about your financial responsibilities.

What Is “Balance Billing” (Sometimes Called “Surprise Billing”)?

When you visit a doctor or other healthcare provider, you may be responsible for out-of-pocket costs like copayments, coinsurance, or deductibles. If you see a provider or go to a facility that’s not in your health plan’s network, you could face additional charges—or even be billed for the full cost of care.

“Out-of-network” refers to providers and facilities that don’t have a contract with your health plan. These providers may bill you for the difference between what your plan pays and what they charge—a practice known as “balance billing.” This amount is often much higher than in-network costs and may not count toward your deductible or out-of-pocket maximum.

“Surprise billing” happens when you receive an unexpected balance bill—often in situations beyond your control, such as during an emergency or when you’re treated by an out-of-network provider at an in-network facility. These surprise bills can be significant, sometimes totaling thousands of dollars depending on the care received.

You’re Protected From Balance Billing For:

Emergency Services

If you have a medical emergency and receive care from an out-of-network provider or facility, you’ll only be responsible for your plan’s in-network cost-sharing amounts—like copays, coinsurance, or deductibles. You cannot be balance billed for these emergency services. This protection also applies to any care you receive after you’re stabilized, unless you choose to give written consent to waive your rights and accept out-of-network charges for that continued care.

Certain Services at an In-Network Hospital or Ambulatory Surgical Center

When you receive care at an in-network hospital or ambulatory surgical center, some of the providers involved in your care—such as those in emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgery, hospitalist, or intensivist roles—may not be in your health plan’s network. Even so, these out-of-network providers can only charge you your plan’s in-network cost-sharing amounts. They cannot balance bill you and may not ask you to waive your protections.

For other types of services at in-network facilities, out-of-network providers also cannot balance bill you—unless you give written consent and agree to give up these protections.

You are never obligated to waive your protections against balance billing, and you’re not required to receive care from out-of-network providers. You always have the option to choose a provider or facility within your health plan’s network.

Most New Yorkers are protected from surprise medical bills if they, or their employer, purchased health insurance within New York State. If your health plan was purchased outside of New York, it’s important to check with your insurance provider to understand the protections available in that state.

Federal protections apply if your employer provides self-funded coverage, but New York’s state-specific protections do not. To find out if your plan is self-funded, check your insurance ID card. If it doesn’t say “fully insured coverage,” your plan is likely self-funded.

When Balance Billing Isn’t Allowed, You Also Have These Protections

  • You’re only responsible for your usual share of the costs—such as copayments, coinsurance, and deductibles—as if you were receiving care from an in-network provider or facility. Your health plan will cover any remaining payments directly to the out-of-network provider or facility.
  • In general, your health plan is required to:
    • Cover emergency services without needing pre-approval for services in advance (also known as “prior authorization”).
    • Cover emergency care provided by out-of-network providers.
    • Calculate your share of the costs (like copays or coinsurance) based on in-network rates, and clearly show this in your explanation of benefits.
    • Apply any payments you make for emergency or out-of-network services toward your in-network deductible and out-of-pocket maximum.

If You Think You’ve Been Wrongly Billed

Contact the federal phone number for information and complaints: 1-800-985-3059.

Visit www.cms.gov/nosurprises/consumers for more information about your rights under federal law.

Visit https://www.dfs.ny.gov/consumers/health_insurance/protections_federal_no_surprises_act for more information about your rights under New York State laws.