PPO Plans- Starting July 1st. No More Surprises

PPO Plans- Starting July 1st. No More Surprises

Under a new state law, if you visit an in-network facility - such as a hospital, lab or imaging center - you will be responsible only for your in-network share of the cost, even if you're seen by an out-of-network provider.

The law applies to non-emergency services received on or after July 1.

Here's a common scenario: A patient takes pains to ensure their hospital and surgeon are in network, only to get billed by the out-of-network anesthesiologist who appears at their bedside to put them under.

No one gets to pick their anesthesiologist, it depends on who is on duty, who is available. Surprise bills also often come from pathologists, radiologists and assistant surgeons - other providers that patients typically can't choose.

The new law covers Californians with private health insurance plans that are regulated by the state Department of Managed Health Care (DMHC) and the state Department of Insurance, which includes roughly 70 percent of the state's private insurance market, according to the California Health Care Foundation.

Under a new state law, if you visit an in-network facility - such as a hospital, lab or imaging center - you will be responsible only for your in-network share of the cost

It does not cover some 5.7 million people whose employer-sponsored insurance plans are regulated by the U.S. Department of Labor.

The key point to remember is that you shouldn't pay more than your in-network copayment, coinsurance or deductible, as long as you visited an in-network facility for non-emergency services. So, if you receive what looks like a bill from a provider showing an out-of-network rate, don't panic.

First, read it carefully. It may not actually be a bill. Under the law, any communication to the patient from an out-of-network provider before that provider gets the consumer's in-network cost information must say - in bold, 12-point type - that it is "not a bill."

If it's an out-of-network doctor, they shouldn't be claiming that you owe anything right away, and don't pay anything until you receive an Explanation of Benefits from your insurer.

How does it work for Emergency Services in an emergency room? As of January 1st, 2017, you cannot be billed out-of-network charges for both emergency room and physician services.

Stephanie Frisch

Stephanie Frisch is the owner of Insurance 101 and is an independent insurance broker dedicated to helping others make “educated decisions” about their insurance choices when it comes to Medicare, Long-Term Care Planning, The Health Insurance Marketplace-Covered California and Life Insurance. For answers to your questions, or an in-home, no-fee consultation, call (949) 351-2443.