Individuals enrolled in fully insured managed care plans in Virginia and state employees will benefit from a new law adopted by the 2020 Session of the Virginia General Assembly to curb balance billing.
Surprise billing – or balance billing – occurs when patients enrolled in managed care health insurance plans receive bills for more than their plan’s cost-sharing amounts directly from medical service providers who do not participate in a managed care plan’s network of providers – often referred to as “out-of-network” providers.
The new law may extend to individuals covered under private insurance they purchase on their own or through their employer. Individuals whose primary coverage is through the state employee health benefit plan and those covered through a health benefit plan purchased through HealthCare.gov cannot be balance billed for situations covered under the new law. Approximately 40 percent of individuals who receive their health insurance through their employer will have this protection under their fully insured plan.
The remaining 60 percent have coverage through a self-funded ERISA or other arrangement where their employer provides benefits that are administered by a third party, which could be a health insurance company. Most of these health plans will have the option to become elective group health plans by choosing to provide these protections for their employees.
For the same protection to apply to individuals enrolled in elective group plans, the plans must choose to opt in by completing and submitting an online application to the State Corporation Commission’sBureau of Insurance at scc.virginia.gov.
They have until Dec. 2, to do so for protection to be effective on Jan. 1. Applications submitted after that date may be effective at a later date.
Plans that opt in will be listed on the Bureau’s website with other information provided by the Bureau regarding balancing billing. Health plans and healthcare providers can go to Balance Billing under the Regulated Industries tab on the Bureau’s website at scc.virginia.gov.
Consumer information regarding balancing billing is available by going to Balance Billing Protections under the Consumers tab on the Bureau’s website.
Under the new law, health care facilities and other providers must provide patients with notifications that address how you are protected, when you can be balance billed, and what to do if you are billed too much. Health insurers regulated by the Bureau also must provide notification to enrollees regarding whether they are subject to balance billing and under what circumstances.
Individuals enrolled in plans covered under the new law or plans that have opted into the new law cannot be billed amounts above their cost-share responsibility by an out-of-network provider for emergency services or for certain non-emergency services – including surgery, anesthesia, pathology, radiology and hospitalist service – during a scheduled procedure at an in-network hospital or other health care facility.
If a consumer is treated by an out-of-network health care provider for services covered by the new 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” that is based on payments for the same or similar services in a similar geographic area, thereby eliminating any balance payment by the consumer to the provider for services rendered.
The Bureau will make available on its website a data set that may be used to determine “commercially reasonable” payment amounts to providers. The data utilizes Virginia’s All-Payer Claims Database as an independent source of claims payment information.
As part of the claims resolution process under the balance billing law, the insurer and provider must first try to agree on a payment amount. If they cannot, one of the parties may request arbitration. Applications for individuals interested in becoming arbitrators will soon be available on the Bureau’s website along with instructions for applying. The Bureau’s website will offer a list of approved arbitrators from which parties entering arbitration may choose.
If health care providers have a pattern of violations under the new law without attempting corrective action, they are subject to fines or other remedies by the Virginia Board of Medicine or the Virginia Commissioner of Health. Similarly, insurance companies that are found to engage in a pattern of violations of the new law are subject to fines or other remedies by the SCC.
Neither insurance companies nor health care providers may use arbitration as a general business practice for resolving claims payments.
For more information, contact the Virginia Bureau of Insurance toll-free at 1-877-310-6560 or visit its website at scc.virginia.gov.
Questions related to the arbitrator application, requests to arbitrate, or questions regarding the self-funded opt-in process may be emailed to [email protected].
Consumer questions and complaints about balance billing may be emailed to [email protected].
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