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Balance Billing

BALANCE BILLING PROTECTION FOR OUT-OF-NETWORK SERVICES

Starting January 1, 2021, Virginia state law may protect you from “balance billing” when you get:

  • EMERGENCY SERVICES from an out-of-network hospital, or an out-of-network doctor or other medical provider at a hospital; or
  • NON-EMERGENCY SURGICAL OR ANCILLARY SERVICES from an out-of-network lab or health care professional at an in-network hospital, ambulatory surgical center or other health care facility.

What is balance billing?

  • An “IN-NETWORK” health care provider has signed a contract with your health insurance plan. Providers who haven’t signed a contract with your health plan are called “OUT-OF-NETWORK” providers.
  • In-network providers have agreed to accept the amounts paid by your health plan after you, the patient, has paid for all required cost sharing (copayments, coinsurance and deductibles for covered services).
  • But, if you get all or part of your care from out-of-network providers, you could be billed for the difference
    between what your plan pays to the provider and the amount the provider bills you. This is called “balance billing.”
  • The new Virginia law prevents certain balance billing, but it does not apply to all health plans.

Applies

* Fully insured managed care plans including those bought through HealthCare.gov
* The state employee health plan
* Group health plans that opt-in

May Apply

* Employer-based coverage
* Health plans issued to an employer outside Virginia
* Short-item limited duration plans

Does Not Apply

* Health plans issued to an association outside Virginia
* Health plans that do not use a network of providers
* Limited benefit plans

How can I find out if I am protected?

Be sure to check your plan documents or contact your health plan to find out if you are protected by this law. When you schedule a medical service, ask your health care provider if they are in-network. Insurers are required to tell you (on their websites or on request) which providers are in their networks. Hospitals and other health care providers also must tell you (on their websites or on request) which insurance plans they contract with as in-network providers. Whenever possible, you should use in-network providers for your health care to avoid paying more.

After you receive medical services, your health plan will send you an “Explanation of Benefits” (EOB) that will tell you what you must pay the provider. Save the EOB and check that any bills you receive are not more than the amount listed.

When you cannot be balance billed:

If the new law applies to your health plan, an out-of-network provider can no longer balance bill or collect more than your plan’s in-network cost-sharing amounts for either (1) emergency care or (2) when you receive lab or professional services (like surgery, anesthesiology, pathology, radiology, and hospitalist services) at an in-network facility.

What should I know about these situations?

Your cost-sharing amount will be based on what your plan usually pays an in-network provider in your area. These payments must count toward your in-network deductible and out-of-pocket limit. If the out-of-network provider collects more than this from you, the provider must refund the excess with interest.

Exception: If you have a high deductible health plan with a Health Savings Account (HSA) or a catastrophic health plan, you must pay any additional amounts your plan is required to pay to the provider, up to the amount of your deductible.

What if I am billed too much?

If you are billed an amount more than your payment responsibility shown on your EOB, or you believe you’ve been wrongly billed, you can file a complaint with the State Corporation Commission’s (SCC) Bureau of Insurance.

To contact the SCC for questions about this notice visit: scc.virginia.gov or call: 1-877-310-6560.

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