HARRISONBURG, Va. (WHSV) — Virginia’s General Assembly passed a new law during its session this year to protect Virginians from getting surprise medical bills.
“When a patient goes to a hospital or medical facility that’s in their health insurance plan, they expect that any cost other than co-pays, deductibles and co-insurance will be covered by your insurance company,” Katha Treanor, Communications Manager for the State Corporation Commission said.
However, there are times when a patient may get services from someone who is an out-of-network provider.
“They’ve checked and made sure it was in their network, and then they still come to find out that an anesthesiologist or radiologist or someone else administered services,” Treanor said.
And that would mean the patient would get billed for the entire cost of their services.
“In that case, it can result in charges in the hundreds or thousands of dollars that the patient is not expecting,” Treanor said.
This new law, which goes into effect on January 1, would protect Virginians from getting those surprise bills. Instead, the insurer or health plan would negotiate with the provider to pay them a “commercially reasonable rate” that is based on payments for the same or similar services in a similar geographic area.
If they cannot agree on an amount, one of the parties can request arbitration.
“Individuals whose primary coverage is through the state employee health benefit plan and those covered through a health benefit plan purchased through HealthCare.gov cannot be balance billed for situations covered under the new law,” according to the SCC. Not everyone will automatically be covered under these new protections.
“Someone who purchases coverage or enrolls in coverage through an employer that has a self-funded plan is not going to be covered under this unless the plan opts-in,” Treanor said.
The deadline to opt-in for the plan starting next year is December 2, 2020. Applications can still be accepted after this date, but they would be effective at a later date. The State Corporation Commission will soon have a list of plans that have opted in on its website.
Additionally, you may not be covered for the new protections for services that you receive out of state, even if you are a Virginia resident.
According to the SCC, “If health care providers have a pattern of violations under the new law without attempting corrective action, they are subject to fines or other remedies by the Virginia Board of Medicine or the Virginia Commissioner of Health. Similarly, insurance companies that are found to engage in a pattern of violations of the new law are subject to fines or other remedies by the SCC. Neither insurance companies nor health care providers may use arbitration as a general business practice for resolving claims payments.”
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