Research shows many consumers are confused about how health care costs work and often have concerns regarding their out-of-pocket costs. At Mather Hospital Northwell Health, we’re here to provide clarity and help you understand what to expect regarding your cost of care and any potential financial responsibility you may have.
If you have health insurance, it’s important to understand the details of your specific plan, as well as how physician, hospital and facility charges work. If you do not have health insurance, we can help by exploring personalized options that may be available for you.
Understanding your insurance
Since any out-of-pocket costs are determined by the details outlined by your insurance plan product, it’s important to understand the specifics – including what’s in-network and what you may be financially responsible for.
Mather Hospital Northwell Health is a participating provider in many health plan networks. Some plans use smaller networks for certain products they offer, so it’s important to check whether or not we participate in the specific plan you are covered by. See if your insurance is accepted.
Avoiding surprise balance bills
If Mather Hospital Northwell Health as a whole or the treating provider does not contract with your specific health plan, Northwell hospitals and/or providers will be considered “out-of-network” (“OON”). Receiving services from an OON provider will result in additional out-of-pocket costs to patients. Patients will be responsible for these costs including any copay, coinsurance, deductible and the difference between the charges billed to and paid by the health plan. This balance is commonly referred to as a “balance bill”. Northwell will happily provide patients with a “good faith estimate” of costs for services in advance so that there are no surprise balance bills. If a patient is not aware and does not consent to services from an OON physician, hospital or facility prior to the services being provided, this is considered a “surprise bill” or a “surprise balance bill”.
Patient protections against surprise balance bills
- Patient responsibility to pay for emergency services provided in an OON hospital or free-standing emergency room is limited to cost-sharing that would be applicable as if the hospital or free-standing emergency room participated with the patient’s health plan.
- Patient responsibility to pay for OON providers providing emergency services at in-network hospitals or free-standing emergency departments is limited to cost sharing that would be applicable if the OON emergency services were provided in-network.
- Patient responsibility to pay for OON providers providing ancillary services at an in-network hospital is limited to in-network cost sharing unless notice and patient consent is given prior to the service. These ancillary services may include services related to emergency medicine, anesthesiology, pathology, radiology, neonatology, services provided by assistant surgeons, hospitalists and intensivists and the laboratory.
- Patient responsibility for OON providers providing non-emergency services is limited to cost sharing that would be applicable for such in-network non-emergency services unless patient is provided prior notice and consents to having services provided by an OON provider.
- Patient responsibility for OON providers providing care in an emergency or pursuant to an emergency admission is limited to cost sharing that would be applicable for such in-network care.
- Patient responsibility for OON providers providing air ambulance services is limited to cost sharing that would be applicable for such in-network air ambulance services.
- Even if care is provided at in-network hospital, the providers who work at that hospital are not included in the hospital fees and will bill separately. These providers may or may not participate with the health plan. Ask your provider what type of other providers might provide care while you are in the hospital.
- You are never required to get OON care. You can choose a provider in your health plan’s network.
Good faith cost estimates are available to protect patients against surprise bills
You have the right to receive a good faith estimate for the total expected cost of any non-emergency items or services. This includes related costs such as medical tests, prescription drugs, equipment and hospital fees. One way to prevent surprise and/or balance bills is to get a good faith estimate for your care. To get a good faith estimate please call (631) 686-7907.
You have the right to receive a good faith estimate outlining how much your medical care is expected to cost. Health care providers are required to give patients who don’t have insurance, or who are not using insurance, a cost estimate for medical items and services. Make sure you receive a good faith estimate in writing at least one (1) business day before your anticipated medical service or item. You can also request a good faith estimate before scheduling an item or service. If you receive a bill that is $400 or more than your good faith estimate, you can dispute the bill. Make sure to save a copy or picture of your good faith estimate.