Balance Billing Protection

Effective January 1, 2021, Virginia state law protects members from balance or “surprise billing.” Elective (self-funded) Group Health Plans must opt-in to this balance billing law at least 30 days prior to their effective date if they would like to offer this protection to their employees. Employers can choose to opt in effective January 1 or effective on the first day of the group’s plan year.

What's Covered

Under the new law, an out-of-network provider can no longer balance bill or collect more than the member’s plan in-network cost-sharing amounts for either:

  1. Emergency services, regardless of the final diagnosis, from an out-of-network hospital,
    out-of-network doctor, or other medical providers at a hospital.
  2. Non-emergency surgery or ancillary professional services for a covered benefit provided by an out- of-network provider at an in-network 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 gets services from an out–of–network provider, who does not have contracted rates with the insurer. 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 pays for the service.  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.

The amount the health insurer pays the facility or provider must bea "commercially reasonable amount" based on payments for the same or similar services in a certain geographic area. If the health plan and the provider cannot agree on the 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 group health plans must opt-in to balance billing by completing and submitting one elective group health plan opt-in form for each applicable group number at least 30 days prior to the group’s effective date. We have created these steps to help employers navigate the site and fill out the form.

Employer groups can track their election status on the SCC Elective Group Health Plan Search page. If an employer group would like to change opt-in information, terminate from the opt-in, or make a change to previously submitted information, they must complete and submit the Elective Group Health Plan Opt-In Change/Request Termination form.