Balance Billing Protection

Effective January 1, 2021, all fully insured groups and elective (self-insured) groups who chose to opt-in received protection through the balance billing law under Virginia legislation.

Starting on or after January 1, 2022, all group and Individual & Family plans will have Federal protections. This change will take effect on January 1, 2022 for Individual & Family plans, and on the first day of the group plan year for group plans. To learn more about the Federal balance billing law, which is part of the No Surprises Act, visit cms.gov/nosurprises.

Balance billing or "surprise billing" occurs when a member receives services from a non-participating provider who does not have contracted rates with the insurer or administrator. In addition to any applicable out-of-network deductible and cost-share amounts, the member pays the balance of the provider’s rate minus what the insurer or administrator pays for the service as outlined in the member’s Explanation of Benefits (EOB).

Please see the consumer rights notice on optimahealth.com.

Changes Under the Federal No Surprises Act

When compared to the Virginia balance billing protections, the Federal No Surprises Act (NSA) contains the following key differences and newly protected services:

  • Post-stabilization and air ambulance services are now protected from balance billing.
  • Cost sharing is calculated differently. However, members are still only responsible for in-network cost sharing.
  • Updates have been made to the process and timeline for resolving payment disputes between providers and health plans.

Check your coverage documents for more information on how the new protections apply to your health plan. To understand whether Virginia balance billing or Federal NSA applies, view this helpful chart from the Virginia Bureau of Insurance (BOI) State Corporation Commission (SCC).

Federal Provider Dispute Resolution Processes

In the case that an independent dispute resolution (IDR) is necessary, Federal costs may include:

    • Each party (plan sponsor/carrier and provider) must pay a $50 administration fee at the time the IDR entity is selected and agreed upon by both parties.
    • Each party must pay a certified IDR entity fee at the time each party submits their offer.
      • The Centers for Medicare & Medicaid Services (CMS) set the following permissible ranges for fees charged by an IDR entity for 2022: $200–$500 for single cases or $268-$670 for batched cases. The party that loses is responsible for the fee, which will be returned to the winning party at the conclusion of arbitration.

If you have more questions regarding the Federal balance billing law, please refer to the Frequently Asked Questions.

What's Covered Under the Virginia Balance Billing Protection

A non-participating provider subject to this law cannot balance bill or collect more than the member’s in-network cost-sharing amounts for either:

  1. Emergency services, regardless of the final diagnosis, from a non-participating hospital, doctor, or other medical providers at a hospital.
  2. Non-emergency surgery or ancillary professional services for a covered benefit provided by a non-participating provider at a participating hospital, ambulatory surgical center, or other healthcare facility, including surgery, anesthesiology, pathology, radiology, or hospitalist services and laboratory services.

Virginia Balance Billing Arbitration Process

The negotiation process begins with the non-participating provider submitting a "clean claim" for the outstanding balance to the carrier. Within 30 days of the submission of a clean claim, the carrier must offer to pay a commercially reasonable amount, based on payments for the same or similar services provided in a similar geographic area. If the provider disputes the carrier’s payment, the provider must notify the carrier within 30 days of receipt of payment / payment notification, whichever is earlier. The carrier and the provider are to negotiate in good faith to agree on a payment amount within those 30 days. If no agreement is reached within such 30-day period, the dispute may then be resolved by initiating arbitration.

Opt-In and Opt-Out Process for Virginia Elective Group Health Plans

Self-funded employers should visit the Virginia BOI SCC website to make any changes to their status, which includes choosing to opt-in, renew, or opt-out of Virginia protections for their upcoming 2022 plan year. Most changes need to be made 30 days prior to the group’s effective date.

If your group opted-in to the Virginia balance billing protections with the "Auto Renewal" option, the Virginia protections will continue. At the time the group renews January 1, 2022 or after, the group will be protected from balance billing under both Virginia law and the No Surprises Act. This means that the two laws will work together, with Virginia law applying first, and in cases where Virginia law does not offer protection, the federal law will be initiated.

If you have more questions regarding the Virginia balance billing law, please refer to the Frequently Asked Questions.

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