Balance Billing Protection in 2022

In January 2021, a Virginia balance billing law was passed to protect fully insured health plan members from receiving an unexpected balance bill from an out-of-network provider for emergency services and for some non-emergency services administered by out-of-network providers at in-network facilities. Elective (self-funded) group health plans were also eligible to opt-in to this Virginia balance billing law.

Changes Under the Federal No Surprises Act

Effective on the first day of a health plan’s 2022 coverage or plan year, health insurance plans offered through group coverage or through the individual market will include federal balance billing protections through the No Surprises Act. This applies to all fully insured and self-funded groups. Some differences from the Virginia rule include:

  • Covered services have been extended to include post-stabilization and air ambulance services.
  • Cost sharing is calculated differently (members will still be responsible for in-network cost sharing).
  • The provider and health plan payment dispute process (independent dispute resolution, or IDR) is slightly different when federal rules apply.

Visit our balance billing page for details on potential federal administration costs.

Existing Virginia Balance Billing Rules

The existing Virginia balance billing rules remain in effect for all fully insured groups and for self-funded groups that chose to opt-in. These protections will be coordinated with federal protections depending on the type and place of service.

Opt-In and Opt-Out Process for Virginia Self-Funded Groups (30 days in advance of effective date)

Most self-funded plans in Virginia remain eligible to continue to opt-in to Virginia balance billing rules. Groups should work with their legal counsel to determine the best option for their new plan year starting in 2022. As a reminder, if groups would like to opt-in to the Virginia balance billing law for the first time, they can follow these steps to navigate the Bureau of Insurance (BOI) State Corporation Commission (SCC) website and fill out the Elective Group Health Plan Opt-In form. If a group would like to change their opt-in information, terminate from the opt-in, or change previously submitted information, they must complete and submit the Elective Group Health Plan Opt-In Change/Request for Termination form. In either case, the BOI SCC will determine if groups are eligible, and if so, what their effective date will be.

Groups must also notify Optima Health of any changes to their opt-in status. If you have any questions, please view our balance billing page or contact your Optima Health representative.