Balance Billing Protection

Effective January 1, 2021, all fully insured groups and self-insured groups who opt-in are protected from balance billing or “surprise billing” by the new balance billing law under Virginia legislation. Elective (level-funded or self-funded) Group Health Plans must submit the opt-in form at least 30 days in advance of the effective date of the election to participate. The effective date for participation can be January 1 of any year or the first day of the group health plan’s plan year.

The new Virginia law prevents certain balance billing, but it does not apply to all health plans. Please refer to the compliance notice for more information.

What's Covered

Under the new law, a non-participating provider subject to this law can no longer 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.

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.  

The amount the insurer or administrator pays the facility or provider must be a "commercially reasonable amount" based on payments for the same or similar services in a similar geographic area. If the insurer or administrator and the provider cannot agree on the payment amount, either party can start the arbitration process. If you have more questions regarding balance billing please refer to the balance billing FAQ.

Opt–In Process for Elective Group Health Plans

Elective (level-funded or self-funded) Group Health Plans must submit the opt-in form for each applicable group number at least 30 days in advance of the effective date of the election to participate (January 1 of any year or the first day of the group health plan's plan year).  We have created these steps to help employers navigate the site and fill out the form.

Groups can track the status of their election on the Elective Group Health Plan Search Page. If a group would like to change their opt-in information, terminate their opt-in status, or make a change to their previously submitted information, they must complete and submit the Elective Group Health Plan Opt-In Change/Request Termination Form.

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