Calculator for the Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act

A.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).

 

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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.

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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.

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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.

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

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To estimate how much your care might cost if you use an out-of-network provider, please use this calculator.¹

Members can also sign in 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.

¹This 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.

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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.

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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.

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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.

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

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We are here to help. You can:

• Sign in 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.

Examples of Anticipated out-of-pocket costs for Frequently Billed out-of-network Services
Procedure	CPT Code	Out Of Network Provider (90th percentile of charges)	Plan will pay (70% of charges)	Member out of pocket	In Network Provider
Coronary Bypass (CABG) w/o Cardiac Catheterization	33510	$29,368	$20,558	$8,810	$9,174
Laminectomy	63047	$100,254	$70,178	$30,076	$40,085
Vaginal Delivery	59510	$16,142	$11,299	$4,843	$8,753
Knee Replacement	27445	$10,891	$7,624	$3,267	$3,584
Carpal Tunnel	25431	$39,586	$27,711	$11,875	$18,250
Cataract Removal	66982	$27,305	$19,114	$8,191	$12,820
Mammogram, Digital	77067	$1,072	$750	$322	$477
CT Scan Abdomen w/o contrast	74150	$10,525	$7,368	$3,157	$3,119
Physician Care New Patient	99201	$1,012	$708	$304	$468
Psychotherapy, 30 minutes	90832	$523	$366	$157	$181

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If you receive a bill for any other amount, please contact Horizon and/or file a complaint with the Department of Banking and Insurance: https://www.state.nj.us/dobi/consumer.htm