When you get emergency care or are treated by an out-of-network provider at an in-network facility, you are protected from surprise billing or balance billing.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay, and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not
count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care-like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Insurers are required to tell you which providers and facilities are in their networks. Providers and facilities must tell you with which provider networks they participate. This information is on the insurer’s, provider’s or facility’s website or on request.
You are protected from balance billing for:
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as deductibles, copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services at the same facility that you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Certain services at an in-network facility
When you get services from an in-network facility, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost sharing amount. This applies to emergency medicine, laboratory, surgeon and assistant surgeon services, and professional ancillary services such as anesthesia, pathology, radiology,
neonatology, hospitalist, or intensivist services. These providers can’t balance bill you and can’t ask you to give up your protections not to be balance billed.
If you receive other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have the following protections:
• You are only responsible for paying your share of the cost (like copayments,
coinsurance and deductibles that you would pay if the provider or facility was innetwork). Your health plan will pay out-of-network providers and facilities directly.
• Your health plan generally must:
o Cover emergency services without requiring you to get approval for
services in advance (prior authorization)
o Cover emergency services by out-of-network providers.
o Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network or facility and show that amount in your explanation of benefits.
o Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and in-network out of pocket limit.
If you believe you’ve been wrongly billed, you may call the federal agencies responsible for
enforcing the federal balance billing protection law at: 1-800-985-3059 and/or file a complaint
with the Virginia State Corporation Commission Bureau of Insurance at: scc.virginia.gov/pages/File-Complaint-Consumers or call 1-877-310-6560.
Visit cms.gov/nosurprises for more information about your rights under federal law.
Consumers covered under (i) a fully-insured policy issued in Virginia, (ii) the Virginia state employee health benefit plan; or (iii) a self-funded group that opted-in to the Virginia protections are also protected from balance billing under Virginia law. Visit scc.virginia.gov/pages/Balance- Billing-Protection for more information about your rights under Virginia law