Your Protections for Out-of-Network Emergency Services and Surprise Bills – New York Health Plan Members

Effective for services received on or after April 1, 2015, Beacon Health Options, Inc. (Beacon), formerly known as ValueOptions Inc., has set up new protections to ensure that — in the following circumstances — members of New York health plans administered by Beacon Health Options 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.

1Please 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.

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  • Out-of-Network Emergency Services

    You will not be responsible for the costs of "emergency services" you receive in a hospital, other than any in-network cost-sharing (in-network copay, coinsurance and/or deductible) that applies to such services under your plan. This is true even if:

    • You receive the emergency services at an out-of-network hospital, or
    • An out-of-network provider provides you services during an emergency hospital visit.

    What are emergency services?

    Emergency services generally refer to the following hospital services to treat an emergency condition:

    • Medical screening exams that a hospital's emergency department can perform, including ancillary services routinely used to assess emergency medical conditions, and
    • Additional medical exams and treatment required to stabilize a patient.

    An emergency condition means a medical or behavioral condition that produces symptoms serious enough to qualify it as an emergency condition. An example is if you have severe pain that you know could result in one or more of the following without getting immediate medical attention:

    • Extreme danger to the health of the person experiencing the emergency condition, or a behavioral condition
    • Serious impairment to the bodily functions of the affected person
    • Serious dysfunction of any bodily organ or part of the affected person
    • Serious disfigurement of the affected person

    What are some examples?

    Here are examples of times you would be responsible only for the in-network cost-sharing for out-of-network emergency services:

    • You go to an in-network hospital emergency department and an out-of-network physician is brought in to perform services to treat the emergency condition
    • An ambulance takes you to an out-of-network hospital and you receive emergency services at that out-of-network hospital

    Here are examples of times these protections would not apply:*

    • You receive services from a provider at an out-of-network urgent care center, rather than in a hospital
    • You receive services in a hospital that do not qualify as emergency services, according to the above definition of emergency services

    How does Beacon Health Options process claims for out-of-network emergency services?

    If Beacon Health Options receives a claim for emergency services from an out-of-network provider, we'll pay the claim at the amount we determine to be reasonable for the emergency services — except for any in-network cost-sharing (in-network copay, coinsurance and/or deductible) that applies under your plan.

    If we pay an amount less than what the out-of-network provider charges, Beacon Health Options will send you a notice — either within, or together with, your Explanation of Benefits — explaining that:

    • Your out-of-pocket costs for the emergency services won't be any higher than if you'd received them from an in-network provider,
    • Your cost-sharing for the emergency services may increase if an IDRE (independent dispute resolution entity) decides Beacon Health Options must pay an additional amount(s) for physician services, and
    • You should contact Beacon Health Options if the out-of-network provider bills you for the out-of-network emergency services for amounts greater than your in-network cost-sharing for the services. For instructions, scroll down to "What to Do If You Get a Bill for Out-of-Network Emergency Services or Surprise Bills."
  • Non-Emergency Surprise Bills

    You will not be responsible for the costs of "surprise bills" for out-of-network services, other than any in-network cost-sharing (in-network copay, coinsurance and/or deductible) that applies under your plan.

    What is a "surprise bill"? What are some examples?

    Not all out-of-network services are surprise bills. A surprise bill is a bill for covered non-emergency health care services rendered on or after April 1, 2015, where one of the following situations applies:

    1. You receive covered health services from an out-of-network physician at an in-network hospital or ambulatory surgical center, in any one of the following circumstances:
      • An in-network physician is unavailable

        Example: You are not told that the scheduled in-network surgeon stepped out of the procedure and an out-of-network surgeon stepped in.

      • An out-of-network physician delivers services and you didn't know that physician was out of network

        Example: You receive covered health services at an in-network ambulatory surgical center, and during that visit an out-of-network anesthesiologist provides services to you, without your knowing of that doctor's out-of-network status.

      • You need unexpected medical services while receiving other services

        Example: Unexpected medical needs arise and an out-of-network surgeon is brought in to perform the unexpected services.

      If a network provider was available and you elected to receive services from a non-participating provider anyway, then it is not a surprise bill.
    2. An in-network physician referred you to an out-of-network provider, and you received covered health services without written consent acknowledging that you:
      • Knew that you are being referred to an out-of-network provider, and
      • Knew that getting services from that out-of-network provider could result in costs not covered by Beacon Health Options

      A referral to a non-participating provider occurs when:

      • the health care services are performed by a non-participating health care provider in the participating physician’s office or practice during the course of the same visit;
      • the participating physician sends a specimen taken from the patient in the physician’s office to a non-participating laboratory or pathologist; or
      • for any other health care services when referrals are required under the member’s contract (i.e., a gatekeeper such as HMO or POS)
      • Example 1: You receive covered health services in an in-network physician's office, and during that visit an out-of-network provider in the same office or practice provides services to you, without your written consent that you knew of that provider's out-of-network status and that you may incur non-covered costs.

        Example 2: An in-network physician sends your lab specimen taken during an in-network office visit to an out-of-network lab or pathologist, without your written consent that you knew of that provider's out-of-network status and that you may incur non-covered costs.

    3. An individual covered by a self funded plan receives health services from a provider at a hospital or ambulatory surgical center, where the health care provider did not give the individual certain required information.

    How does Beacon Health Options process claims for non-emergency surprise bills?

    If Beacon Health Options gets a claim for out-of-network services that isn't submitted with a completed surprise bill Assignment of Benefits Form, Beacon Health Options will process the claim as usual – that is, we will deny the claim if you only have in-network coverage, e.g., HMO or EPO, or, if your plan includes out-of-network benefits (usually called a PPO or POS plan), we will process the claim according to the terms and conditions that normally apply to out-of-network services — which usually involve higher cost-sharing and higher out-of-pocket costs than for covered in-network services. We will then send you a notice — either within, or together with, your Explanation of Benefits — explaining that the claim could be a surprise bill, and that you should contact Beacon Health Options or refer to this web page for instructions on what to do next.

    If Beacon Health Options gets a claim for out-of-network services along with a completed surprise bill Assignment of Benefits Form, or a claim that we determine is a surprise bill without also receiving a surprise bill Assignment of Benefits Form, we will send you a notice explaining that:

    • Your out-of-pocket costs for the services related to the surprise bill won't be any higher than if you'd received them from an in-network provider,
    • Your cost-sharing for the services may increase if an IDRE (independent dispute resolution entity) decides that Beacon Health Options must pay an additional amount(s) to the provider for the services, and
    • You should contact Beacon Health Options if the out-of-network provider bills you for the out-of-network service.

    What if Beacon Health Options doesn't know a claim should be handled as a surprise bill?

    We will process the claim as described above and provide notice that it may be a surprise bill.

    If you feel Beacon Health Options should have processed a claim as a surprise bill, you should complete a surprise bill Assignment of Benefits Form and submit it to Beacon Health Options You also have the option to dispute our decision on the claim by filing a grievance.

    For the address and other contact options for submitting forms, and for instructions on filing a grievance, see the section on this page "Disputing Claims for Out-of-Network Emergency Services or Surprise Bills."

  • What to Do If You Get a Bill for Out-of-Network Emergency Services or a Surprise Bill

    If you receive a bill for out-of-network emergency services or you receive a surprise bill for out-of-network services, you should contact us. If it's a surprise bill, the out-of-network provider must provide you with a surprise bill Assignment of Benefits Form as well.

    If you "assign benefits" for a surprise bill in writing to an out-of-network provider who knows you're insured under a health care plan, that provider cannot seek payment from you — except for any in-network cost-sharing (in-network copayment, coinsurance and/or deductible) that applies to the service under the terms of your plan.

    If you receive a surprise bill for out-of-network services and you want to assign benefits, send Beacon Health Options the following documents:

    1. Standard Assignment of Benefits Form (only surprise bills)
    2. Claim form
    3. Copy of the bill

      Documentation can be sent to one of the following:

      Mail PO Box 370
      Latham, NY 12110
      Fax (855) 378-8309
      Email nysurprisebill@beaconhealthoptions.com
    4. Upon receiving this information, we will process a claim for the related services. You must also submit a copy of the Assignment of Benefits form to your provider.
  • Disputing Claims for Out-of-Network Emergency Services or Surprise Bills with Beacon Health Options

    If you disagree with how we processed a claim because you believe the bill was for out-of-network emergency services or a surprise bill, you can do either or both of the following:

    • Call Beacon Health Options Customer Service and tell us you think your claim was for emergency services or is a surprise bill. Please contact the phone number for behavioral health (mental health/substance use) on your ID card. For a surprise bill, you will be required to complete and submit the standard surprise bill Assignment of Benefits Form, plus a copy of the bill you received from your provider. For a surprise bill, you can also simply complete and submit the standard surprise bill Assignment of Benefits Form to Beacon Health Options and to your provider without calling and we will re-evaluate your claim. To submit the information noted in this paragraph, please see below.
      Mail PO Box 370
      Latham, NY 12110
      Fax (855) 378-8309
      Email nysurprisebill@beaconhealthoptions.com

    • Submit a dispute by mail or fax. To file a grievance concerning a claim, please see below.
      Mail PO Box 370
      Latham, NY 12110
      Fax (855) 378-8309

  • How an Out-of-Network Provider Disputes Out-of-Network Emergency Services or Surprise Bill Payments Through the Independent Dispute Resolution Process

    If Beacon Health Options reimburses an out-of-network provider for an emergency service or surprise bill with an amount he or she determines to be unreasonable, or if Beacon Health Options and the provider cannot otherwise agree on an appropriate payment for the service, the provider or Beacon Health Options may submit the dispute to an independent dispute resolution (IDR) process through the New York State Department of Financial Services.

    Members covered under self-insured plans and individuals who do not have insurance may also access the IDR process in some circumstances.

    The following describes how out-of-network providers should proceed to submit a dispute through the IDR process for emergency services or surprise bills:

    • Health care providers for disputes with a health plan involving an insured patient. To submit a dispute, health care providers must:
    • Uninsured patients or patients with employer or union self-insured coverage, or insured patients who do not assign benefits for surprise bills. To submit a dispute, patients must complete this application and send it to NYS Department of Financial Services, Consumer Assistance Unit/IDR Process, One Commerce Plaza, Albany, NY 12257.

    For assistance, call 1-800-342-3736 or e-mail IDRquestions@dfs.ny.gov.

    A physician or health care provider shall provide the following information:

    1. The name and contact information of the physician or non-participating referred health care provider;
    2. The name and contact information of the health care plan;
    3. The fee charged by the physician or non-participating referred health care provider for the service that is the subject of the dispute, and provide a copy of the bill;
    4. The fee paid to the physician or non-participating referred health care provider for the service that is the subject of the dispute;
    5. At least three fees paid to the physician or, if the dispute involves a health care provider to the non-participating referred health care provider, in the last 12 months for the same services rendered by the physician or non-participating referred health care provider to other patients in health care plans in which the physician or non-participating referred health care provider is not participating, if available;
    6. The physician’s or non-participating referred health care provider’s usual charge for comparable services rendered to other patients in health care plans in which the physician or non-participating referred health care provider is not participating;
    7. The physician’s or non-participating referred health care provider’s level of training, education and experience;
    8. An explanation of the circumstances and complexity of the particular case, including time and place of the service;
    9. Individual patient characteristics;
    10. The usual and customary cost for the service, if available and applicable;
    11. Any other information the physician or non-participating referred health care provider deems relevant;
    12. An attestation affirming that the information provided by the physician or non-participating referred health care provider is true and accurate; and
    13. Any information requested by the IDR entity.
  • Estimating Out-of-Network Care Costs

    HMO & EPO Plans:

    If you have an HMO or EPO plan, then your plan generally does not cover out-of-network benefits, except for emergency services. If you still want to receive non-emergency services from an out-of-network provider, it's a good idea to know how much the services will cost. Ask the provider how much he or she charges for any service(s) you will be receiving.

    If you cannot get this information from your provider, you can use the Fair Health Calculator to get an estimate of the Usual, Customary and Reasonable (UCR) rate for services from an out-of-network provider in a given geographic region, based on average health care costs across New York State. Your provider may actually charge you more or less than the UCR rate.

    PPO & POS Plans:

    If you have a PPO or POS plan, then your plan generally does provide benefits for most covered services received from out-of-network providers. The terms and conditions of out-of-network coverage vary depending on the specific plan you have. Beacon Health Options offers tools to help you estimate our payment and your out-of pocket costs for out-of network services. There are two steps to estimating how much you are likely to pay for an out-of-network service:

    1. Identify the provider's charges for an out-of-network service. Before receiving services from an out-of-network provider, ask that provider how much he or she charges for any service(s) you know you will be receiving. If you cannot get this information, you can use the Fair Health Calculator to get an estimate of the approximate dollar amount the out-of-network provider will charge you for the service(s). Note that you will need to have the procedure code(s) and certain other information about the services to use the calculator. This Calculator provides the Usual, Customary and Reasonable (UCR) rate for services from an out-of-network provider in a given geographic region, based on average health care costs across New York State. Your provider may actually charge you more or less than the UCR rate.
    2. Determine the difference between the Beacon Health Options' allowance and the charges of the out-of-network provider. You will be responsible for the difference between Beacon Health Options' allowance (maximum amount we pay for a service) and charge(s) from the out-of-network provider, as well as for any out-of-network cost-sharing that applies to the service under the terms of your plan. To identify Beacon Health Options' allowance for a specific service, please contact the phone number for behavioral health (mental health/substance use) on your ID card.

    Note: Beacon Health Options' allowance will generally not reflect any applicable cost-sharing (i.e., copayment, deductible and/or coinsurance), which you must also pay toward the service(s) and will reduce the amount of the allowance actually payable by Beacon Health Options See your member contract or certificate of coverage for the cost-sharing that applies under your plan. Benefits will be subject to all terms, conditions, limitations and exclusions set forth in your plan. Benefit estimates are not a guarantee. The actual payment will depend on a number of factors, including, for example, the services you receive, the amount billed by your physician or other provider, the actual procedure codes submitted and your eligibility for benefits at the time you receive services

  • Important Words to Know

    Allowance: What a plan will pay for covered out-of-network services before cost-sharing is applied.

    Cost-Sharing: The portion of the plan's schedule or allowance that plan members pay to use covered health services. There are three possible types of cost-sharing: copay, coinsurance and deductible. The amount of these costs depends on your specific health plan. For out-of-network benefits, cost-sharing does not include the difference between Beacon Health Options' allowance and the provider's charges, which you are also responsible to pay (in addition to cost-sharing).

    Explanation of Benefits (EOB): A summary of our payment decision(s) relating to a claim for health care services.

    In-Network Provider: A physician or other health care provider, or a health care facility, that participates in your health plan's provider network.

    Network: Group of physicians, hospitals and other health care providers with whom a health insurer contracts to deliver medical services to its plan members.

    Out-of-Network Provider: A physician or other health care provider, or a health care facility, who does not participate in your health plan's provider network.

  • FAQs

    Out-of-Network Emergency Services

    How are “emergency services” defined?

    Emergency services generally refer to the following services provided to treat an emergency condition:

    1. Medical screening exams that a hospital’s emergency department can perform, including ancillary services routinely used to assess emergency medical conditions, and
    2. Additional medical exams and treatment required to stabilize a patient.

    An emergency condition means a medical or behavioral condition that produces symptoms serious enough to qualify it as an emergency condition. An example is if you have severe pain that you know could result in one or more of the following without getting immediate medical attention:

    • Extreme danger to the health of the person experiencing the emergency condition, or a behavioral condition
    • Serious impairment to the bodily functions of the affected person
    • Serious dysfunction of any bodily organ or part of the affected person
    • Serious disfigurement of the affected person

    Do the emergency services protections apply to my Beacon Health Options plan?

    The emergency services protections described apply to insured plan members whose health plan is administered by Beacon Health Options and whose plan includes 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 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.

    Do the emergency services protections apply to emergency services I receive at an out-of-network urgent care center?

    No. To be eligible for these protections, emergency services must be received in a hospital.

    An ambulance took me to an in-network hospital. Without knowing it, I received emergency services from an out-of-network provider at that hospital. Am I responsible for the costs?

    Since this was an emergency, you’re only responsible for paying your in-network cost-sharing (in-network copay, coinsurance and/or deductible) for the ambulance ride, the hospital visit and for the care you received from the out-of-network proovider.

    How does Beacon Health Options process claims for out-of-network emergency services?

    If Beacon Health Options receives a claim for emergency services from an out-of-network provider, we’ll pay the claim at the amount we determine to be reasonable for the emergency services — except for any in-network cost-sharing (in-network copay, coinsurance and/or deductible) that applies under your plan.

    If we pay an amount less than what the out-of-network provider charges, Beacon Health Options will send you a notice — either within, or together with, your Explanation of Benefits — explaining that:

    • Your out-of-pocket costs for the emergency services won’t be any higher than if you’d received them from an in-network provider,
    • Your cost-sharing for the emergency services may increase if an IDRE (independent dispute resolution entity) decides Beacon Health Options must pay an additional amount(s) for the physician services, and
    • You should contact Beacon Health Options if the out-of-network provider bills you for the out-of-network emergency services except for your in-network cost-sharing amount. For instructions, see the section “What to Do If You Get a Bill for Out-of-Network Emergency Services or Surprise Bills.”

    We will also inform the out-of-network physician how to initiate the independent dispute resolution process in the event the physician is unsatisfied with our payment.

    Non-Emergency Surprise Bills

    What’s a "surprise bill"?

    A surprise bill is a bill for covered non-emergency health care services, where one of the following situations applies:

    1. You receive covered health services from an out-of-network physician at an in-network hospital or ambulatory surgical center, where either:
      • An in-network physician is unavailable
      • An out-of-network physician delivers services without your knowledge
      • You need unexpected medical services while receiving other services
      If you received the health care services when a network physician was available and you elected to obtain services from the out-of-network physician anyway, it is not a surprise bill.
    2. An in-network physician referred you to an out-of-network provider, and you received covered health services from the out-of-network provider without your written consent acknowledging that you:
      • Knew the referred provider was outside your plan’s provider network, and
      • Knew that getting services from that out-of-network provider could result in costs not covered by Beacon Health Options
      A referral to an out-of-network provider occurs when:
      • Health care services are performed by an out-of-network provider in the network physician’s office or practice during the course of the same visit,
      • The network physician sends a specimen taken from the patient in the network physician’s office to an out-of-network laboratory or pathologist, or
      • For any other health care services performed by an out-of-network provider, when referrals are required under your health plan contract or certificate of coverage.
    3. A self-insured or uninsured individual receives health services from a provider at a hospital or ambulatory surgical center, where the provider did not share required information with a patient in a certain time frame.

    Do the surprise bills protections apply to my Beacon Health Options plan?

    The surprise bills protections described apply to insured plan members whose health plan is administered by Beacon Health Options and whose plan includes 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 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.

    How do I know if a bill is a surprise bill?

    Refer to the sections “Non-Emergency Surprise Bills” and “What to Do If You Get a Bill for Out-of-Network Emergency Services or a Surprise Bill.” If you still have questions, please contact the phone number for behavioral health (mental health/substance use) on your ID card.

    Do these protections apply to services I choose to receive from an out-of-network provider?

    Generally, no. If you knowingly opt to receive non-emergency services from an out-of-network provider rather than from in-network providers, the protections do not apply and you will be responsible for paying for the services of the out-of-network provider.

    If your plan includes out-of-network benefits (usually called a PPO or POS plan), you generally will have benefits for most covered services even if you receive them out-of-network, but the cost-sharing and out-of-pocket expenses will generally be higher than if you had obtained services in-network. Be sure to check whether your plan has out-of-network benefits, and please review your contract or certificate of coverage for the terms and conditions of your out-of-network coverage.

    I chose to see a provider who it turns out is not in my plan’s provider network. Do the protections apply?

    Generally, no. In most cases, you are responsible for all bills for covered services you choose to receive from providers who are not in your plan’s provider network (usually called an HMO or EPO plan). So, before seeing a provider, be sure to confirm the provider participates in your plan’s provider network by checking the online provider directory, asking the provider’s office when making an appointment, or calling Beacon Health Options to ask.

    If your plan covers out-of-network services (usually called a PPO or POS plan), the out-of-network services may be eligible for coverage, according to the terms of your plan’s coverage for out-of-network services, though usually at higher cost-sharing and with more out-of-pocket costs than in-network services.

    During my non-emergency surgery at an in-network hospital or surgical center, an out-of-network physician stepped in to perform services without my knowing it. Am I responsible for the costs?

    Since you didn’t know you were getting out-of-network care, the protections apply and you are not responsible for any costs other than any applicable in-network cost-sharing (in-network copay, coinsurance and/or deductible) you owe under your plan.

    My in-network primary care physician referred me to an out-of-network provider, and I saw that provider without knowing of her out-of-network status. Am I responsible for the costs?

    It depends. If the referral occurred under a contract that requires referrals from PCPs or the referral was to another provider in your physician's office or practice and you see the other provider during the course of the same visit with your physician where the referral occurred, then you are not responsible for any costs other than the applicable in-network cost-sharing you owe under your plan. If your physician referred you to an out-of-network provider outside of these situations, then you are responsible for the costs.

    I had blood drawn in an in-network physician's office, but the sample was sent to an out-of-network lab for testing. Am I responsible for the costs?

    Since you did not consent in writing to have the blood sample sent to an out-of-network lab, you are not responsible for any costs beyond any applicable in-network cost-sharing you owe under your plan for the service.

    Handling Surprise Bills

    What should I do if I get a surprise bill from a provider’s office?

    If a provider sends you a bill for a surprise bill, he or she must also provide you with an Assignment of Benefits Form. Complete and send this form, along with a copy of the bill, to Beacon Health Options by mail or email for processing.

    Mail PO Box 370
    Latham, NY 12110
    Fax (855) 378-8309
    Email nysurprisebill@beaconhealthoptions.com

    For instructions on submitting these documents, see the section “What to Do If You Get a Bill for Out-of-Network Emergency Services or a Surprise Bill.” You also must submit a copy of the Assignment of Benefits Form to your provider.

    Beacon Health Options has already processed a claim for what I believe is a surprise bill, but I am being asked to pay more than my in-network cost-sharing. What should I do?

    You should complete and submit to Beacon Health Options a standard surprise bill Assignment of Benefits Form, or contact the phone number for behavioral health (mental health/substance use) on your ID card. Customer Service will ask you to complete and submit the standard surprise bill Assignment of Benefits Form when you call.

    If you feel a payment decision is incorrect, you also can file a grievance with Beacon Health Options by calling Customer Service or submitting a dispute by mail, fax or email.

    For instructions on submitting forms and filing grievances, see the section “Disputing Claims for Out-of-Network Emergency Services or Surprise Bills.”

    Estimating Out-of-Network Care Costs

    What is cost-sharing?

    Cost-sharing describes the portion of our plan allowances that you are responsible for paying. There are a few types of cost-sharing (i.e., copay, coinsurance and/or deductible) that plan members may need to pay to use covered health services. Cost-sharing does not include premiums, which is the cost of your health care plan either each month or over a given time period. If your plan includes out-of-network coverage, cost-sharing also does not include the difference between the Beacon Health Options' allowance (the maximum amount we pay for a service) and the charges of an out-of-network provider, which you are also responsible for paying.

    If I receive out-of-network emergency services or services that would qualify as a “surprise bill,” will my cost-sharing and out-of-pocket costs be higher than if I had received in-network care?

    No. In these cases, your cost-sharing will be at the in-network cost-sharing amount(s), as defined under your plan.

    Is there any way to estimate what I would pay out of pocket for out-of-network services?

    Yes. To identify Beacon Health Options' allowance for a specific service, please contact us at the phone number for behavioral health (mental health/substance use) on your ID card.

    Beacon Health Options Provider Networks

    How do I know if a provider participates in my plan’s provider network?

    To find a provider that participates in your plan use our provider search tool on MemberConnect. If you are a registered user please login or you may enter as a guest and follow the prompts.

    If a provider says they participate with Beacon Health Options, are they sure to be in my plan’s provider network?

    No. Providers may participate in some Beacon Health Options' networks, but not in others. So, when you make an appointment to see a provider, be sure to tell the provider’s office which type of coverage you have.

    Will Beacon Health Options be making changes to any of its provider networks to account for the new protections for out-of-network emergency services and surprise bills?

    No. At this time, Beacon Health Options will not be changing our provider networks based on these new protections.

    More Information

    Where can I get more information on the out-of-network payment protections?

    Please visit the dedicated web page of New York State’s Department of Financial Services.

    Questions?

    Please contact Beacon Health Options at the phone number for behavioral health (mental health/substance use) on your ID card. 8 a.m. to 8 p.m. ET, Monday – Friday (excluding major holidays). TTY/TDD users, please call 711.

    1Please 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 also 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.