New York’s Emergency Services and Surprise Bills law was created to provide consumer protections from medical bills received from out-of-network physicians for services rendered in emergency rooms.  It also requires disclosures regarding out-of-pocket expenses to be made by health plans, providers and hospitals, and imposes network adequacy rules upon health plans with comprehensive provider networks.

Emergency Services

For emergency services, patients are only responsible for in-network costs and will not be liable to pay more than their usual cost sharing or co-payments, regardless of whether the providers were in-network or out-of-network.

Disclosure Requirements 

Health care providers must disclose information to patients regarding the health plans with which the provider participates, hospital affiliations, and the availability of anticipated charges, upon request from the patient, with a warning that such costs may increase due to unforeseen medical circumstances.

Physicians must advise patients of additional providers who might be involved in the patient’s care, and also advise both patients and hospitals prior to a scheduled hospital admission or outpatient hospital service of the providers whose services will be arranged by the physician and how to determine the plans in which the physician participates.

Hospitals must post on their websites information such as a list of the hospital’s standard charges for items and services provided by the hospital; affiliated medical practices and employed physicians; health plans in which it participates; and a detailed statement that physician services provided are not included in the hospital charges and physicians providing services may or may not participate in the same health plans.

Non-Emergency Services

Other non-emergency services provided by out-of-network providers may be considered a “surprise bill” requiring only payment of in-network costs when the care was provided by an out-of-network provider and there was no in-network provider available; the patient was referred by a participating physician and he/she did not explicitly consent to the referral to a non-participating provider; or the patient did not receive the disclosures required under the law.

Independent Review Process

In the event of a dispute between providers and health plan over the fee charged for medical services, there is an independent review process to deal with the dispute.  However, there is an exclusion for bills for emergency services resulting in charges less than $600.

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