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Balance Billing Protection
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Balance Billing Protection

Virginia’s new balance billing law and rules, effective January 1, 2021, protects consumers from getting billed by an out-of-network health care provider for emergency services at a hospital or for certain non-emergency services during a scheduled procedure at an in-network hospital or other health care facility. The law covers emergency services, laboratory services, and any professional non-emergency services, including:

  • Surgery
  • Anesthesia
  • Pathology
  • Radiology
  • Hospitalist services
If a consumer is treated by an out-of-network provider or facility for services covered by the new law, the provider or facility will submit the claim to the consumer’s insurer. They will be paid a “commercially reasonable amount” which is based on payments for the same or similar services in a similar geographic area. The insurer and facility or provider must first try to agree on this amount. 

What should I do if I get a surprise medical bill?

Effective Jan. 1, 2021, you cannot be balance billed or surprise billed for certain services.
  • Contact the provider or facility and tell them you believe you've been wrongly billed. Request that your bill be lowered.
  • After contacting the medical provider, you can also contact your insurance company for assistance.
    • Reference your policy or member ID card for your insurance company's contact information or use our License Lookup to find their contact information.
  • If you are still unsatisfied after contacting the medical provider and your insurance company, you can also file a complaint with our office and we will review your case.
  • If the medical provider and your insurer are unable to agree on an acceptable payment, the provider and the insurer can then enter arbitration.
    • Arbitration will only affect what you will pay if you are covered by a catastrophic or high deductible health plan with a Health Savings Account (HSA) and have not reached your full deductible amount.

Does the Virginia law apply to my health plan?

The Virginia surprise balance billing law applies to:
  • all Virginia-regulated managed care plans
  • plans bought through HealthCare.gov
  • state employee health benefit plans 
Self-funded group health plans not regulated by Virginia and certain other self-funded group health plans mentioned in the balance billing law may opt-in to offer the balance billing protections to their enrollees. 

List of Elective Group Health Plans Opted-In to Balance Billing

If your plan is not on the list, you should check your plan documents or contact your health plan for information on whether this law applies to your health plan.  

How much must I pay for a surprise medical bill? 

  • You are not responsible for paying a surprise medical bill if the protections apply. Your insurer must pay the out-of-network provider and facility directly.
  • You are only responsible to pay for what you would normally pay for the same service from an in-network provider, including any copays, coinsurance and deductible.

What health insurers must do 

  • Base your financial responsibility on what you would pay an in-network provider or in-network facility in your area and show the amount on your Explanation of Benefits (EOB).
    • Exception: if you have a high deductible health plan with a Health Savings Account (HSA) or a catastrophic health plan, you may need to pay additional costs, but you still will not be responsible for more than your cost share. 
  • Include any amount you pay for emergency services or certain out-of-network services at an in-network facility toward your in-network deductible and out-of-pocket limit.
  • Provide the names of providers, hospitals, and facilities that are in-network.
  • Provide notice to you of your rights (in English, Spanish, Korean, or Vietnamese) under the balance billing law and let you know when you can and cannot be balance billed. 
  • For coverage effective or renewing January 1, 2022 and after, federal surprise balance billing protections also become effective. The Bureau, in consultation with other interested parties, developed this notice to be used for coverage that falls under the protections of both Virginia and federal surprise balance billing laws. 

What medical providers and facilities must do

  • Tell you which provider networks they participate in.
  • Refund any amount you overpay within 30 business days.
  • Provide notice to you of your rights (in English, Spanish, Korean, or Vietnamese) under the balance billing law to let you know when you can and cannot be balance billed. As of January 1, 2022, provide this notice to those protected by Virginia’s balance billing law.
  • Not ask you to limit or give up these rights.

Reporting

Federal No Surprises Act

Congress enacted the No Surprises Act (NSA) in December 2020, as part of the Consolidated Appropriations Act of 2021.  This Act provides protection to consumers even where the Virginia law may not apply.

NSA Balance Billing External Review Process

The federally-administered Balance Billing External Review process is available when your insurer covers a service but indicates that the provider can balance bill you or bill you for a cost share that is higher than that allowed under the federal NSA.  Additional information about the NSA External Review process can be found at:  https://externalappeal.cms.gov.  You may call 888-866-6205 ext. 3326 if you have questions concerning the External Review process.


Consumer notice

The Bureau has prepared a notice carriers and providers should use to inform consumers of their balance billing rights. We intend for this notice to satisfy the requirements of both the federal No Surprises Act and Virginia's laws.

You can email your questions or concerns to bureauofinsurance@scc.virginia.gov.