Avoiding NYSHIP pitfalls

 

FYI: Know your rights as a health
insurance consumer
in New York state.

 

  • Even if you see an in-network doctor, they may send any tests or blood-work to an out-of-network lab, which won’t be covered. To avoid nasty surprise bills, always make absolutely sure to specify to your doctor that only an in-network lab should be used. Find an in-network lab in this directory.
  • Whenever you call any NYSHIP service provider to pre-authorize a procedure or for any advice or information, it’s absolutely crucial that you tell the representative you speak to, not just that you’re covered by NYSHIP, but also that your coverage is under the specific sub-category of the NYSHIP Student Employee Health Plan (SEHP). Make sure that they understand exactly which plan you have and that they explicitly confirm to you that any information they give you is accurate specifically for NYSHIP (SEHP).Our benefits are different from those of most NYSHIP members, but reps tend to assume that you have the more common version of the plan—which can result in their giving you the wrong info and land up costing you thousands of dollars.

    You should also always make a note of the number you called, the full name of the person you speak to, and the date, start time, and duration of your call.
  • Getting a procedure done by an in-network doctor? Whether it’s done on-site at their office or in hospital, check very carefully and well beforehand that everyone involved in the procedure is in-network (all nurses, assistants, medical consultants, anesthesiologists, etc.). Check also that all aspects of the procedure are covered (post-procedure care, all medical technology, drugs, and supplies used, follow-up care and consultations, etc.) It may be wise to check, beforehand, both with the doctor themselves and with their administrative and billing staff. Make sure that everyone you speak to explicitly and unambiguously confirms that all elements of your procedure are covered by your insurance.
  • Got a surprise bill from NYSHIP? Remember that you have the right to challenge it, but you should do so immediately. Follow the details given on the invoice itself. You may also contact Student Affair’s NYSHIP Coordinator, Scott Voorhees, for assistance. And, of course, we encourage you to get in touch with us at DSC Health & Wellness; we’re happy to offer any advice and assistance we can.
    • Note that there is now “a provision of the law that protects patients from being responsible for paying the full charge for surprise bills. This provision,  which generally applies only to services provided within New York State, applies when patients are treated by nonparticipating providers without their knowledge. If you have questions about whether a bill meets this definition, contact DFS at 1-800-342-3736 or visit www.dfs.ny.gov/consumer/hprotection.htm.” (from the April 2016 update to the SEHP plan)
I should be covered for this, but my NYSHIP service provider is refusing to authorize/pay for this service, despite my complaint. What do I do?

If any of NYSHIP’s providers (such as the Empire Plan, for instance) are refusing to pay for services for which you should be covered—you have recourse to a number of bodies whose mandate it is to defend your right to all coverage that you’re entitled to. You can find more advice on how to appeal a denied claim here: “Navigating insurance claims and appeals.” If you have already followed the complaint procedure detailed on the invoice from your health insurance provider, without success, the following may well be able to help you:

The Health Care Bureau protects and advocates for the rights of all health care consumers statewide. They operate a toll-free Health Care Helpline, 1-800-428-9071.

The Bureau helps New Yorkers with individual healthcare and insurance problems; investigates deceptive business practices; takes law enforcement actions to address systemic problems in the operation of the healthcare system; and where appropriate, proposes legislation to enhance healthcare quality and availability in New York State.

Consumers have the right to an external appeal when healthcare services are denied by an HMO or insurer (health plan) as not medically necessary, experimental/investigational, a clinical trial, a rare disease treatment, or, in certain cases, as out-of-network.

External appeal requests must be submitted to the New York State Department of Financial Services and the Department will assign independent medical experts to review the appeal.

If you’ve got any advice on avoiding NYSHIP pitfalls, please let us know! Any tips to help other students with NYSHIP avoid incurring unexpected costs or to negotiate their way around NYSHIP difficulties are very welcome. And see more information about NYSHIP pitfalls in the Powerpoint below!

NYSHIP presentation for the joint DSC Health & Wellness / Adjunct Project NYSHIP Student-led Workshop

Download (PPTX, 255KB)


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