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Balance Billing Law + -

Overview

Virginia’s new balance billing law, 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.

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. 

Learn more about how this legislation affects you on this page.

Balance Billing: Notice of Consumer Rights

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 May Apply Does Not Apply
  • Fully insured managed care plans, including those bought through HealthCare.gov
  • The state employee health plan o Group health plans that opt-in
  • Employer-based coverage
  • Health plans issued to an employer outside Virginia
  • Short-term limited duration plans
  • Health plans issued to 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.

Balance Billing Legislation FAQs

This document seeks to provide answers to frequently asked questions (FAQs) for Virginia residents and direct them to available resources for further assistance.

View the FAQS > 

Understanding Hospital Charges

Thank you for your interest in understanding more about hospital charges. Contained in this file you will find information that complies with the pricing transparency requirements prescribed by the Centers for Medicare & Medicaid Services (CMS). In those requirements, hospitals must provide several different  types of charging elements. In general, it is useful to create a distinction between two different types of charges that exist in the healthcare industry.

The first Is "gross charge" that relates to the established prices that are billed to all patients regardless of insurance coverage. The second Is "negotiated charge" that relates to prices insurance  companies have agreed to pay for services. All patients will receive the same "gross charge" for items and services at the hospital, however, "negotiated charge" will vary based on agreements that exist with insurance companies.  If a patient is insured, he or she will typically be responsible for a portion of the negotiated charge.  The portion of the charge  that an uninsured or insured patient will pay a hospital for services Is referred to as "out of pocket" expense. An insured patient's out of pocket expense will be dependent on the Type of coverage the patient has with the insurance company. Uninsured patients should contact a hospital representative to assist with options for payment.

The CMS hopes information from this file can be utilized by researchers and developers to better understand hospital charges for purposes of enhanced transparency and communication.

View the File >

List of Carrier Provider Networks

As a unified family of providers, Chesapeake Regional Healthcare brings a broad range of care to the people of southeast Virginia and northeast North Carolina through Chesapeake Regional Medical Center (CRMC), Chesapeake Regional Medical Group (CRMG), and its affiliate services. A local, independent, community-focused organization, Chesapeake Regional Healthcare offers area residents what they want: high quality, technologically advanced health care delivered by people who openly display their caring, concern and compassion.

The file here contains information on which health insurance carriers we have partnered with.

Individual patient responsibility can be discussed by contacting hospital or insurance representatives. Please do not hesitate to contact us at 757-312-8121. 

View the List of Carrier Provider Networks >