Commonly referred to as the ban-on-balance billing laws (see September 2000 Voice for more details), they have kept out-of-pocket expenses down for our municipal retirees and survivors. Yet the question persists: Then why am I being billed and can my doctor charge me?

“We’ve found in most cases that the members are not being billed for the balance over the allowable rate,” reports Stillman. “But they are being charged the amount which the insurance company has not paid toward the allowable rate ($100).”

Unfortunately, indemnity plans, now being offered by BC/BS and other insurance carriers to municipalities, may no longer require that 100% of the allowable rate be paid to the physician. In most cases, these local plans require that only 80% be paid, leaving a balance - 20% of the allowable rate - owed to the physician.

This may also be true in connection with the Medicare supplement plans that they currently offer at the local level. Instead of picking up the 20% of the allowable rate not paid by Medicare, these plans may not pay anything.

Going back to our earlier example, under these current plans, the physician is still banned from charging the $50 balance over the $100 allowable rate. But, since only $80 was paid toward the allowable rate, the physician could bill the local retiree or survivor for the $20 still owed on the rate.

“It’s important to review the specifics of your municipal plan and, if your doctor bills you, to first check with your insurance company about the charges,” suggests Stillman. “And of course, we’re always there to help.”