Note: This information applies to enrollees of The Empire Plan.
2026 Changes
If you receive emergency care or certain services from a non-network provider that you did not choose, you are protected from surprise billing—generally paying only what you would have if the provider(s) had been in the Empire Plan network. In these situations, The Empire Plan and the nonnetwork provider mutually determine how much the plan should pay. If there is disagreement, the matter may be settled through a process called independent dispute resolution (IDR).
Award Limits
In some cases, IDR has led to provider awards that significantly exceed typical reimbursement amounts. To control costs and slow premium growth, New York State recently established limits on these awards. According to the new law:
- The provider submits their fee and The Empire Plan submits its allowed amount.
- The IDR arbitrator must generally choose the amount that is closest to the 50th percentile of amounts allowed for the service among similar local providers.
- The award amount is limited to the 80th percentile of amounts allowed for the service among similar local providers. Disputes involving hospital-employed physicians are not subject to the new rules.
In addition, awards will not be given to non-network providers in any of the following cases:
- The Empire Plan issued a predetermination or preauthorization notice to the provider clearly identifying the covered services as non-network.
- You signed a written consent form indicating you knew the covered services were non-network.
- The Empire Plan demonstrates that the provider is in fact a network provider.
You Remain Protected
These changes do not alter surprise billing protections for patients. If you receive a surprise bill, submit a Surprise Medical Bill Certification Form. For more, see the Surprise Medical Bills page of the NYS Department of Financial Services website.
Remember, the best way to save yourself and the plan money is by staying in the network of providers and facilities.
