Virginia’s new balance billing lawand 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 Iget 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 lawapplies to:
- all Virginia-regulated managed care plans
- plans bought through HealthCare.gov in Virginia or through Virginia’s Insurance Marketplace
- Virginia state employee health benefit plans
Self-funded group health plans not regulated by Virginia and certain other self-funded group health plansmentioned 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-networkdeductible 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 balancebilled.
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 balancebilled.
- Not ask you to limit or give up these rights.
Reporting
- Balance Billing Arbitration Process Annual Report – Dec. 2023
- Balance Billing Arbitration Process Annual Report – July 2023
- Balance Billing Arbitration Process Annual Report – Dec.2022
- Balance Billing Arbitration Process Annual Report – July 2022
- Balance Billing Arbitration Process Annual Report – Dec. 2021
- Balance Billing Arbitration Process Annual Report – June 2021
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.
- Read about the new federal No Surprises Act(www.cms.gov)
- FAQ - Consumer Protections from Surprise Medical Bills
No Surprises Act (NSA) External Review Process
The NSA expanded the scope of the External Review process to allow for appeals regarding whether your insurer is complying with surprise billing and cost-sharing protections under the NSA. This includes situations such as when your insurer determines that your cost-sharing responsibility for a surprise bill higher than that allowed under the NSA. Additional information about the NSA External Review process can be found at:https://externalappeal.cms.gov. For general questions regarding the NSA, you may contact the NSA Help Desk at 1-800-985-3059 from 8 am to 8 pm EST, 7 days a week.
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.
- Virginia and Federal No Surprises Act consumer notice
- The Future of Balance Billing in Virginia PowerPoint
You can email your questions or concerns to bureauofinsurance@scc.virginia.gov.
