YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS

Fertility Institute of New Jersey & New York (Regional Women’s Health Group) – a community of caring, connected, progressive health professionals committed to giving women more – is providing this notice as required by the federal No Surprises Act.

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.

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

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.

Click here to learn more about your rights and protections against surprise medical billing.

You’re Protected From Balance Billing For:

Emergency Services

If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You cannot be balance billed for these emergency services. This includes services you may get after you’re in stable condition unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

In addition to the protections under federal law, New Jersey law prohibits certain out-of-network facilities and providers from charging you more than your plan’s in-network cost-sharing amount for services furnished on an emergency or urgent basis if your plan is regulated under state law.

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, or 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 cannot balance bill you, unless you give written consent and give up your protections.

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.

In addition to the protections under federal law, New Jersey law prohibits certain out-of-network providers from charging you more than your plan’s in-network cost-sharing amount for non- emergency services furnished at an in-network facility if your plan is regulated under state law.

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

  • You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible 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
  • 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
    • 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.

YOUR RIGHTS TO RECEIVE A GOOD FAITH ESTIMATE

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.  This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

Click here to learn more about your rights to receive a Good Faith Estimate.

If you think you’ve been wrongly billed, contact the CMS No Surprises Helpdesk at 1-800-985-3059

Visit www.cms.gov/nosurprises/consumers for more information about your rights under the federal No Surprises Act.

Visit https://www.state.nj.us/dobi/division_consumers/insurance/outofnetwork.html for more information about your rights under New Jersey law.