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What you need to know about surprise bills

New Jersey has a new law, the Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act (the “Act”), to help protect you from surprise bills, including bills for emergency services from doctors, hospitals and other health care professionals who are not in your health plan’s network (also called out-of-network providers).

The questions and answers below can help you understand out-of-network care, surprise bills and how the Act can help you.

What is the “Act”?

The Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act (the “Act”), effective August 30, 2018, mandates that health insurance carriers and providers comply with certain disclosure, reimbursement and arbitration requirements when a member receives services from out-of-network doctors, facilities, such as hospitals and ambulatory surgery centers, and other health care professionals (also called out-of-network providers).

What is an out-of-network provider?

An out-of-network provider is a doctor, hospital or other health care professional who treats you, but is not in your health plan’s network. Out-of-network care can cost you much more out of your own pocket.

If your health plan includes benefits for out-of-network care, you can choose to receive care from an out-of-network provider. However, if you do not intentionally choose to get care from an out-of-network provider, you may get a surprise bill for services.

What is a surprise bill?

A surprise bill is a bill you receive for care provided by an out-of-network provider in certain circumstance, including if:

• You have a procedure at a hospital or surgery center that is in your health plan’s network, and while you were there, you also received care from an out-of-network provider because:
  • An in-network provider wasn’t available.
  • You didn't know you were getting care from an out-of-network provider.
  • A medical need that you or your doctor(s) did not expect required you to get care from an out-of-network provider.
• You were referred by an in-network provider to an out-of-network provider and you didn’t sign a consent form to show you understood there may be extra cost to you. This may happen when:
  • During your visit with an in-network provider, you get care from an out-of-network provider who practices in the same office.
  • Your in-network provider takes a specimen (for example, blood or tissue sample) in his or her office and sends it to a lab or pathologist that is not in your health plan’s network. This is called “inadvertent out-of-network services.”
  • Your in-network provider refers you to an out-of-network provider when referrals are required under your health plan, and your in-network provider did not get advance approval from Horizon BCBSNJ.
• You experience a medical emergency and the nearest hospital is not in your health plan’s network. In this case, you should get the care you need, regardless of the hospital’s network status, and you should not pay more than what you would be required to pay if you received the necessary care at an in-network hospital.

A bill is not considered a surprise bill if you choose to receive services from an out-of-network provider when an in-network provider is available.

What should I do if I get a surprise bill?

If you receive a surprise bill, you should first contact the provider to see if it was issued in error. If the answer is no, and the bill is for anything more than your in-network copayment, deductible or coinsurance, inform Horizon BCBSNJ. You also have the right to report it to DOBI.

The Act includes provisions that require good faith negotiation and binding arbitration for reimbursement disputes pertaining to out-of-network services. Here is an overview of how arbitration will work:

• The out-of-network provider submits a surprise out-of-network claim for services.
• Horizon BCBSNJ must pay the charges or notify the out-of-network provider within 20 days of receiving the claim that the charges are considered excessive.
• If Horizon BCBSNJ sends notice that the charges are excessive, the parties have 30 days to negotiate a settlement for the claim.
• If no settlement is reached after 30 days, Horizon BCBSNJ will issue payment to the out-of-network provider, which shall be deemed Horizon BCBSNJ’s final offer.
• However, if there is still a payment dispute and the difference between the parties’ final offers is more than $1,000, Horizon BCBSNJ, the out-of-network provider, or the member may initiate binding arbitration by filing a request with DOBI within 30 days of the out-of-network provider’s final offer.
• The arbitrator will choose one of the two amounts submitted by the parties as final offers, and the decision is binding on both parties. The arbitrator’s decision will be issued within 30 days after the request is filed with DOBI.
• Any amount awarded by the arbitrator in excess of the payment already made, must be paid within 20 days. Interest charges will begin to accrue 20 days after the arbitrator’s decision.
• The arbitrator’s expenses and fees will be paid equally among the parties, except if the arbitrator determines that Horizon BCBSNJ’s payment was not made in good faith. In this case, Horizon BCBSNJ will be responsible for all of the arbitrator’s expenses and fees.

Are there instances when the negotiation and arbitration process does not apply?

Negotiations and arbitration do not apply to a member who knowingly, voluntarily and specifically selects an out-of-network provider for health care services.

How can I find out how about out-of-network costs?

To estimate how much your care might cost if you use an out-of-network provider, please visit fairhealthconsumer.org. ^[1]

Members can also sign in to HorizonBlue.com to use our Treatment Cost Estimator to estimate how much the same care might cost if provided by an in-network doctor, hospital or other health care professional.

You can expect your costs to be lower when you use an in-network provider for your care.

 

^{1. This link will take you to a website that is not owned or controlled by Horizon Blue Cross Blue Shield of New Jersey. The cost estimates you receive through fairhealthconsumer.org will depend on the information you provide, and actual costs may differ depending on what the provider bills and your benefits.}

What happens if I use an out-of-network provider?

Your costs for care may be higher if you use an out-of-network provider.

In addition, a hospital or other health care facility must inform you in advance if any out-of-network providers will be involved in your care. If you do not receive this information before you receive care, you will only be responsible for paying your in-network deductible, copayment or coinsurance amounts.

If I go to an in-network hospital, will all of the doctors and other health care professionals also be in my health plan’s network?

It depends. Sometimes specialists, such as Emergency Room (ER) doctors, anesthesiologists, radiologists or pathologists, may not be in your health plan’s network. For example, you may go to an in-network hospital and get an X-ray, but the doctor who reads your X-ray may not be in your health plan’s network.

How do I make sure I get care from an in-network provider?

When you get care, be sure to state that you want only in-network providers to treat you. If a new doctor or other health care professional joins your care team or advises on your care, be sure to ask if he or she is in your health plan’s network.

How can I find a doctor, hospital or other health care professional that is in my health plan’s network?

You can use our Doctor& Hospital Finder to find in-network providers.

Who can I contact with questions?

We are here to help. You can:

• Sign in at HorizonBlue.com to send us an email, 24/7, or chat with us during normal business hours.
• Call the Member Services phone number on the back of your member ID card during normal business hours. If you are not yet a member, please call us at 1-800-355-BLUE (2853).
• Call our After Business Hours hotline at 1-833-876-3825 from 6 p.m. to 12 a.m., Eastern Time, on Monday, Tuesday, Wednesday and Friday, and from 6 p.m. to 1 a.m., Eastern Time, on Thursday. Representatives can help you with questions about your out-of-network benefits, out-of-pocket costs and how to find an in-network doctor or hospital.

What will I find on this website?

This website is here to help both insured and uninsured people make decisions about healthcare. The cost lookup tool shows you what medical care costs in your area. At this time, we have cost estimates for:

• Thousands of medical services (professional fees);
• Medical supplies (e.g., diabetes supplies, walkers, canes, vision supplies, hearing aids);
• Anesthesia services;
• Ambulance rides; and
• Services done in a facility (e.g., hospital or ambulatory surgery center).

This website allows you to search for:

• How much you might pay for a medical service if you're uninsured.
• Out-of-network costs that you may pay if you go to doctors who are not in your health plan's network.
• For in-network costs, you can estimate how much you may have to pay for doctors in your health plan's network if you haven't met your deductible.

Do the medical cost estimates apply to people who are covered by Medicare, Medicaid or other government programs?

No. The cost estimates generally apply only to those who are covered by private insurance or who are uninsured. These cost estimates do not apply to those who are covered by government programs such as Medicare, Medicaid or Tricare.

However, these cost estimates may be useful to you if you have coverage under a government program, but you are getting care that is not covered by that program. For example, Medicare does not cover most dental services. If you have Medicare and you need to see a dentist, you can find out how much you may pay. The information on the site can also help you evaluate a Medicare Advantage plan that requires you to pay more for services outside of the plan's network.

Note: Some private insurers (i.e., non-government) use Medicare rates to set out-of-network reimbursement, which means that the insurer will pay some percentage or multiple of what Medicare would have paid for the services. This is not the same as being covered by Medicare. If your insurer refers to Medicare rates in this way, you can use this website to estimate your medical out-of-pocket cost: on the cost results page, selecting the appropriate option under the “Estimated Reimbursement” dropdown section under “Adjust Charge.”

I searched for a cost estimate and got "N/A." What does it mean?

If you see N/A (Not Available) after searching for a cost estimate, this means that we cannot provide at this time a cost estimate for the procedure code in the geographic area you searched.

Search Limits

Why does the website limit the number of searches I can conduct?

• This website is for consumer use. It is expected that in most cases, consumers will be able to meet their needs before reaching the search limits: When looking up medical costs, search up to 20 medical codes per week. Entering a zip code and a medical procedure code (or choosing a procedure from the menu) counts as one medical search.

Search limits are reset at the end of the weekly search period to enable consumers to estimate costs for additional codes.

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