Many Virginians are already protected against surprise medical bills – thanks to a Virginia law that took effect January 1, 2021. Now, the federal No Surprises Act (NSA), which takes effect January 1, 2022, will provide additional protections for more people against surprise billing for medical expenses.
Surprise billing – or balance billing – occurs when patients enrolled in managed care health insurance plans receive care either in an emergency situation or unknowingly from medical service providers who do not participate in the plan’s network of providers – often referred to as “out-of-network” providers – and the provider bills them for more than their plan’s cost-sharing amounts (such as deductibles, coinsurance and copays).
Virginians enrolled in either fully insured managed care health insurance plans issued in Virginia, or the state employee health benefit plan, must not be balance billed by an out-of-network provider for emergency services. Additionally, out-of-network providers cannot balance bill these individuals for certain non-emergency services during a scheduled procedure at an in-network hospital or other health care facility.
Self-insured group health plans may opt-in to the protections offered by Virginia’s balance billing laws. In Virginia, these plans are known as elective group health plans. Please visit the State Corporation Commission’s (SCC) Bureau of Insurance (Bureau) balance billing webpage at https://www.scc.virginia.gov/balancebilling to view plans that have chosen to opt-in to Virginia’s protections.
Most people who receive health care coverage through an employer are covered by self-insured health plans. The new NSA applies to items and services provided to individuals enrolled in self-insured health plans offered by employers regardless of the location of the employer or balance billing protections offered by a state, as well as group or individual health care coverage offered through health insurance companies.
New NSA protections – which include cost-sharing rules, prohibitions on balance billing for certain items and services, notice and consent requirements, and requirements related to disclosures about balance billing protections – apply to health care providers and facilities, as well as providers of air ambulance services.
The NSA makes an independent dispute resolution (IDR) process available for providers and insurance companies to settle disputes about a patient’s bill without putting the patient in the middle. Under the NSA, IDR is also available in certain circumstances for individuals who are uninsured.
Some states have their own balance billing IDRs. Virginia law provides a process for insurers and providers to resolve balance billing disputes and prohibits the provider from balance billing the consumer. When a consumer is treated by an out-of-network health care provider for services covered by the law, the provider will submit the claim to the consumer’s insurer or health plan. The insurer or health plan will pay the provider a “commercially reasonable amount,” thereby eliminating any balance payment by the consumer to the provider for services rendered.
The out-of-network provider may dispute the payment amount with the insurer. If that occurs, one of the parties may request that an arbitrator determine the final payment amount and resolve the dispute. Arbitrators must report their final decision to both arbitrating parties and to the Bureau. In support of this dispute resolution process, currently 111 arbitrators have been approved in Virginia. Between January 1, 2021, and October 31, 2021, the Bureau received 727 arbitration requests, 660 of which were accepted as eligible.
Virginia law also requires certain consumer notifications by health care facilities, other medical providers and managed care health insurance plans regulated by the Bureau regarding balance billing protection for out-of-network services – including when a consumer can be balance billed and their rights under Virginia law. The Bureau has posted a consumer notification for January 1, 2022, that incorporates new federal rights and protections at: https://www.scc.virginia.gov/pages/Balance-Billing-Protection.
Keep in mind that, under your health plan, you are still responsible for cost-sharing amounts that may include copays, coinsurance and deductibles.
In some cases, Virginia protections may be more extensive than those provided under the NSA, such as with short-term, limited-duration plans with a network and certain types of in-network facilities subject to Virginia law.
If you think your protections have not been applied correctly, you may contact the Virginia Bureau of Insurance toll-free at 1-877-310-6560 or visit https://www.scc.virginia.gov/pages/Balance-Billing-Protection. Consumer questions and complaints about balance billing may be emailed to BureauofInsurance@scc.virginia.gov.
To learn more about your protections under the NSA, visit https://www.cms.gov/nosurprises.
