SCC seeks comment regarding health insurance balance billing

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The State Corporation Commission is seeking written comments on regulations proposed by its Bureau of Insurance that carry out certain provisions of a new Virginia law designed to protect consumers from receiving surprise medical bills.

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.

Under legislation passed by the 2020 General Assembly and signed in April by Gov. Ralph Northam effective Jan. 1, 2021, individuals enrolled in managed care health insurance plans cannot be balance billed in Virginia if they receive emergency services from an out-of-network provider or non-emergency surgical or ancillary (such as diagnostic and support) services from an out-of-network provider at an in-network facility.

The new law incorporates protections for consumers put forth by the Bureau in 2019 as well as adds further protections. Based on the new legislation, the newly proposed regulations replace those advanced last year and establishes procedures for an insurance company and an out-of-network health care provider to arbitrate disputes when they cannot agree on payment for a service. It also establishes qualifications for arbitrators chosen to determine payment disputes.

Additionally, the law sets forth consumer notification requirements for health care facilities and providers regarding balance billing and requires managed care health insurance plans regulated by the Bureau of Insurance to provide notification to enrollees regarding whether they are subject to balance billing and under what circumstances.

Comments or requests for hearing regarding the proposed regulations may be submitted by September 1, 2020, with the Clerk of the Commission, State Corporation Commission, c/o Document Control Center, P.O. Box 2118, Richmond, Virginia 23218 and shall refer to Case No. INS-2020-00136.

Comments may also be submitted through the SCC’s website at scc.virginia.gov/casecomments/Submit-Public-Comments. Simply scroll down to case number INS-2020-00136 and click SUBMIT COMMENTS.

You can also learn more about balance billing from the National Association of Insurance Commissioners’ website.


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