Effective for services received on or after April 1, 2015, Carelon Behavioral Health set up new protections to ensure that — in the following circumstances — members of New York health plans administered by Carelon Behavioral Health will not be responsible for costs other than the in-network cost-sharing (in-network copay, coinsurance and/or deductible) that applies under your plan. These two cases are:
- If you receive out-of-network emergency services in a hospital
- If you receive a non-emergency “surprise bill” for out-of-network services
This page describes these protections, which are effective with dates of service on or after April 1, 2015. It also explains what to do if you feel you have received a surprise bill.
1 Please note that the emergency services and surprise bills protections described do not apply to you if your plan does not include a provider network feature. Some or all of these protections may not apply to you if you are covered under any of the following types of plans or circumstances:
- Self-insured group health plan (other than the New York State Empire Plan);
- Medicare supplement plan;
- Medicare Advantage plan;
- Medicaid Managed Care plan or Medicaid Fee For Service;
- Medicare is your primary coverage (e.g. group health plan retiree benefits that supplement Medicare payments); or
- Other plans and circumstances as may be determined by New York law and regulations and/or the New York State Department of Financial Services.
Click the links below to learn more
- Out-of-Network Emergency Services
- Non-Emergency Surprise Bills
- What to Do If You Get a Bill for Out-of-Network Emergency Services or a Surprise Bill
- Disputing Claims for Out-of-Network Emergency Services or Surprise Bills with Carelon Behavioral Health
- How an Out-of-Network Provider Disputes Out-of-Network Emergency Services or Surprise Bill Payments Through the Independent Dispute Resolution Process
- Estimating Out-of-Network Care Costs
- Important Words to Know
- FAQs