NEW YORK STATE REQUIRED WEBSITE MATERIALS

NEW YORK LAW

 

PROTECTION FROM SURPRISE BILLS

Applicable to: Insureds covered and eligible for benefits under a Nippon Life Insurance Company of America fully-insured health plan that is issued in and subject to New York law (not including self-insured plans).

A "surprise bill" (as defined by applicable New York law, regulation and/or guidance as of the date the services are rendered to the insured) is an invoice that an insured receives for covered health-care services (other than emergency services) RENDERED/PROVIDED TO THE INSURED ON OR AFTER MARCH 31, 2015  under either of the following circumstances:

  • For services performed by an out-of-network physician at an in-network hospital or ambulatory surgical center, when:
    • An in-network physician is unavailable at the time the health care services are performed;
    • An out-of-network physician renders services without the insured's knowledge; or
    • Unforeseen medical issues or services arise at the time the health care services are rendered.
  • An insured is referred by an in-network physician to an out-of-network provider without the insured's explicit written consent acknowledging that the referral is to an out-of-network provider and disclosing that it may result in costs not covered under the insured's health plan.
  • A referral to an out-of-network referred health care provider occurs when:
    • Health care services are performed by an out-of-network health care provider in the in-network physician's office or practice during the course of the same visit; or
    • The in-network physician sends a specimen taken from an insured in the in-network physician's office to an out-of-network laboratory or pathologist.

A SURPRISE BILL DOES NOT INCLUDE A BILL FOR COVERED HEALTH CARE SERVICES WHEN AN IN-NETWORK PHYSICIAN IS AVAILABLE AND AN INSURED ELECTS TO RECEIVE SERVICES FROM AN OUT-OF-NETWORK PHYSICIAN OR PROVIDER.

An insured will be held harmless for any out-of-network physician covered health-care services that qualify as a surprise bill under applicable New York law, regulation and/or guidance as of the date the services are rendered to the insured, and that exceed the insured's health insurance plan's in-network copayment, deductible or coinsurance if:

  1. The insured assigns benefits to the out-of-network physician in writing; and
  2. The insured sends the assignment of benefits form and a copy of the applicable bill or bills in question to the insured's health insurance carrier and physician.

With respect to covered health-care services related to a surprise bill that qualifies as a "surprise bill" under applicable New York law, regulation and/or guidance as of the date the services are rendered to the insured, the out-of-network physician may only bill the insured for the in-network copayment, deductible or coinsurance applicable to the insured's specific health insurance plan. However, please note that the insured's cost-sharing may increase in the event an Independent Dispute Resolution Entity (see below) determines that the insured's health insurance carrier must pay additional amounts for the covered services related to the surprise bill rendered by the out-of-network physician or referred health care provider.

 

New York State Out-of-Network Surprise Medical Bill Assignment of Benefits Form

 

As of 4/17/2015, the New York State Out-of-Network Surprise Medical Bill Assignment of Benefits Form is available here: ( https://www.dfs.ny.gov/docs/insurance/health/OON_assignment_benefits_form.pdf ).

How an Insured May Submit a Claim or Assignment of Benefits Form

A Nippon Life Insurance Company of America insured may submit a claim or assignment of benefits form to Nippon Life Insurance Company of America at:

 

Electronic Claims Payer #81264

Nippon Life Insurance Co. of America

P.0. Box 25951

Shawnee Mission, KS   66225-5951

Customer-Service@nipponlifebenefits.com

 

 

PROTECTION FROM OUT-OF-NETWORK EMERGENCY SERVICES

Hold Harmless Protections for Insured Members. Nippon Life Insurance Company of America must protect an insured from bills for covered out-of-network emergency services in a hospital (as defined by applicable New York law, regulation and/or guidance as of the date the services are rendered to the insured) if the insured is covered and eligible for benefits under a Nippon Life Insurance Company of America fully-insured health plan that is issued in and subject to New York law (not including self-insured plans). An insured will not have to pay non-participating/out-of-network physician charges for emergency services in a hospital that are more than the in-network copayment, coinsurance or deductible applicable under the insured's health insurance plan (this protection may only apply when an insured's health insurance coverage renews after March 31, 2015).

 

 

GENERAL INFORMATION:

 

THE INDEPENDENT DISPUTE RESOLUTION (IDR) PROCESS

New York law, applicable to health care services rendered/provided in New York on and after March 31, 2015, will utilize a dispute resolution process by which a dispute for an invoice related to a "surprise bill" or an invoice related to "out-of-network emergency services" may be resolved.

  • Health Care Providers for Disputes with a Health Plan Involving an Insured Patient.
    • To submit a dispute, health care providers must:
      • Visit the New York Department of Financial Services (DFS) website to receive a file number;
      • Complete the applicable application available on the DFS website (as of 3/23/15, available here: ( http://www.dfs.ny.gov/consumer/health/IDR_Provider_Application.pdf); and
      • Send the application to the assigned independent dispute resolution entity.

 

  • Insureds Who Do Not Assign Benefits for Surprise Bills.

 

 

Review of Surprise Bills and Bills for Out-of-Network Emergency Services by an Independent Dispute Resolution Entity (IDRE)

IDR Entity Review. Disputes are reviewed by independent dispute resolution entities (IDRE). Decisions will be made by a reviewer with training and experience in health care billing, reimbursement, and usual and customary charges in consultation with a licensed doctor in active practice in the same or similar specialty as the doctor providing the service that is the subject of the dispute.

  • 30 Day Timeframe. The IDRE will make a determination within 30 days of receipt of the dispute.
  • The IDRE Determines the Fee. For disputes involving insurance coverage, the IDRE chooses either the non-participating provider bill or the health plan payment. For disputes submitted by uninsured patients, or patients with employer or union self-insured coverage, the IDRE determines the fee.
  • The IDRE Considers the Following Factors When Making a Determination:
    • Whether there is a gross disparity between the fee charged by the provider and (1) fees paid to the provider for the same services provided to other patients in health care plans in which the provider is non-participating, and (2) the fees paid by the health plan to reimburse similarly qualified out-of-network providers for the same services in the same region;
    • The provider's training, education, experience, and usual charge for comparable services when the provider does not participate with the patient's health plan;
    • The circumstances and complexity of the case;
    • Patient characteristics; and
    • The usual and customary cost of the service.
  • The IDRE may direct a good faith negotiation for settlement if settlement is likely or if the health plan's payment and the provider's fee are unreasonably far apart.
  • The Review is Binding (and is admissible in court).

Payment for the IDRE

  • Disputes Between a Provider and a Health Plan, Involving an Insured Patient.
    • The provider pays the cost of the dispute resolution when the IDRE determines that the health plan's payment is reasonable.
    • The health plan pays the cost of the dispute resolution when the IDRE determines that the provider's fee is reasonable.
    • The provider and the health plan share the prorated cost when there is a settlement.
    • There may be a minimal fee to the provider or health plan submitting the dispute if the dispute is found ineligible or incomplete.
  • Disputes Involving a Patient who is Not Insured.
    • The doctor pays the cost of the dispute resolution when the IDRE determines that the doctor's fee is not reasonable.
    • The patient pays the cost of the dispute resolution when the IDRE determines that doctor's fee is reasonable, unless it would pose a hardship to the patient. "Hardship" means a household income below 250% of the Federal Poverty Level.

Questions:

If you have questions or need help completing an application, call (800) 342-3736 or e-mail IDRquestions@dfs.ny.gov.

 

ESTIMATE OUT-OF-NETWORK OUT-OF-POCKET COSTS

 

Nothing herein is a guarantee of benefits or eligibility. All terms, provisions, conditions, limitations and exclusions shown in your Nippon Life Insurance Company of America certificate booklet and master policy will govern.

You may estimate your anticipated out-of-pocket costs for out-of-network covered medical services by contacting your provider for the amount that he/she will charge, or by visiting *www.fairhealthconsumer.org to determine the usual and customary cost for these services in your geographic area or zip code, and comparing it to our estimated payment - you may contact us at 1-800-374-1835 to request our estimated payment for a specific out-of-network service covered under your plan.

Please note that these payment amounts and charges are only an estimate based on the information submitted and not a guaranteed amount. Your actual out-of-pocket costs may differ based on a number of factors, including, for example, your actual plan provisions and benefits, your eligibility, the actual services provided to you, whether the services are covered by your plan, whether the services are medically necessary, the procedure codes submitted by your provider, whether other providers render services to you, the location of the services, your cost-sharing requirements, or other variables that may impact the cost of services. Also, even though your provider may bill separately for multiple procedure codes, we may determine that there is a single code that should have been billed for all of the procedures and we will pay for only that code. At all times, all terms, provisions, conditions, limitations and exclusions shown in your certificate-booklet and master policy will apply and govern.

Please note that this link (www.fairhealthconsumer.org ) is being provided for informational purposes only, and does not constitute an endorsement or approval by Nippon Life Insurance Company of America as to any of the opinions of FAIR Health, Inc. Nippon Life Insurance Company of America bears no responsibility for the accuracy, legality or content of this external site or for that of any subsequent links.

DISCLAIMERS

Please note that any out-of-pocket amounts shown are only an estimate and not a guaranteed amount. Your actual out-of-pocket costs may differ based on a number of factors, including, for example, your actual plan provisions and benefits, your eligibility, the actual services provided to you, whether the services are covered by your plan, whether the services are medically necessary, the procedure codes submitted by your provider, whether other providers render services to you, the location of the services, your cost-sharing requirements, or other variables that may impact the cost of services. Also, even though your provider may bill separately for multiple procedure codes, we may determine that there is a single code that should have been billed for all of the procedures, and we will pay for only that code.

NOTHING HEREIN IS A GUARANTEE OF BENEFITS OR ELIGIBILITY. ALL TERMS, PROVISIONS, CONDITIONS, LIMITITATIONS AND EXCLUSIONS SHOWN IN YOUR NIPPON LIFE INSURANCE COMPANY OF AMERICA CERTIFICATE AND MASTER POLICY WILL GOVERN.

THIS INFORMATION IS PROVIDED FOR GENERAL INFORMATIONAL  PURPOSE ONLY AND IS NOT INTENDED TO OFFER LEGAL, TAX, BENEFITS, MEDICAL OR ANY OTHER PROFESSIONAL ADIVICE. LAW IS SUBJECT TO CHANGE, AND THEREFORE, FOR CONFIRMATION OF CURRRENT  RULES, DETAILS AND GUIDANCE ON HOW THEY MAY IMPACT  PARTICULAR EMPLOYER GROUPS OR INDIVIDUALS, PLEASE CONTACT  YOUR SUBJECT  MATTER EXPERT COUNSELORS.