N.Y. OKs Balance Billing

“When health care service is provided by a participating provider, an HMO must hold its subscriber harmless from charges in excess of any contractual co-payment amounts,” New York officials write in the opinion. “Accordingly, the contract between the HMO and the provider must prohibit balance billing.”

New York state does not impose balance billing restrictions on providers treating patients who have other types of state-regulated coverage, such as non-HMO health insurance, officials write.

The state has jurisdiction over self-funded employer plans offered by government agencies and churches, but officials say the state does not impose substantive requirements on those plans and does not know what they do about balance billing.

State-regulated plans that want to keep the providers who participate in their networks from balance billing can do so by putting balance-billing provisions in provider contracts, officials write.

Similarly, the state has no jurisdiction over self-funded plans or self-funded plans offered along with limited-benefit health plans, and the state has no laws or regulations preventing providers from balance-billing patients with those types of coverage, officials write.