Protecting Consumers from Surprise Medical Bills

Gladys was in a meeting in 2010 when, without warning, she collapsed from a stroke. The 50-year-old single working mom was rushed to the hospital for emergency treatment.  She recovered, and felt lucky.

Then the bills arrived—over $130,000 in hospital and doctor fees. “That was scary,” says Gladys, who had health coverage at the time of her illness.

In 2011, just two weeks after running a 10K race, Joclyn came down with symptoms that felt like pneumonia. An ultrasound revealed a rare condition that required an emergency heart transplant. The surgery was successful. But the medical bills totaling nearly $70,000 for procedures she thought were covered by her insurance came as an unwelcome surprise.

With help from CSS’s Community Health Advocates (CHA) program, Gladys and Joclyn successfully appealed to their insurance companies. But CHA soon realized that a bigger problem was at work, and they began to alert state policymakers and other advocates.

 

 

 

 

 

 

 

 

 

 

 

 

Thousands of New Yorkers are hit with surprise out-of-network medical bills each year. Often, consumers who had done their best to utilize in-network medical care would find that an out-of-network provider, like an anesthesiologist, radiologist, or other specialist, participated in their care. Left to fend for themselves with insurers, many of these consumers incurred insurmountable bills.

Nation's Strongest Protections Against Out-of-Network Billing

All that changed in March 2014, when CSS, through the Health Care for All New York (HCFANY) coalition, successfully partnered with the New York State Department of Financial Services to craft the strongest consumer protection law in the nation to shield consumers from out-of-network surprise medical bills. HCFANY is a statewide coalition of over 170 organizations dedicated to achieving quality, affordable health coverage for all New Yorkers. CSS is a founding member of the HCFANY coalition.

Working tirelessly with allies, other consumer groups, health plans and providers, HCFANY advocates held hearings to educate lawmakers, contacted media outlets, and highlighted powerful stories of those affected by crushing medical debt resulting from these “surprise” bills. These efforts were bolstered by data from the New York Department of Financial Services showing that out-of-network medical bills were the top health insurance-related complaint the department received—and the top cause of personal bankruptcy in the state. 

This concerted advocacy led to a new law that protects people from surprise bills and expands consumer rights and protections.

The new law, which takes effect as of April 1, 2015:

1. Holds consumers harmless from out-of-network emergency bills and non-emergency claims where an in-network provider isn’t available or proper disclosures about network status are not made. Consumers will only have to pay in-network cost-sharing in these situations.

2. Insures that consumers will no longer be left to negotiate surprise bills on their own. Instead, bill negotiation will be left to providers and plans through an independent third party.

3. Improves disclosure by insurance plans and providers, so that consumers can make informed decisions when purchasing a plan and scheduling services.

4. Holds more plans to network adequacy standards and review.

5.Makes the claim submission process more consumer friendly.


 

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