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Open Enrollment Nov. 1 – Dec. 15, 2020

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Balance Billing Protection Opt-in

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SCC News

New Balance Billing Law Takes Effect January 1, 2021; Applications for Opt-in Plans Now Being Accepted/Arbitrator Applications Coming Soon

OCT 30, 2020

RICHMOND – Many Virginians will have protection from surprise medical bills beginning January 1, 2021. Individuals enrolled in fully insured managed care plans in Virginia and state employees will benefit from a new law adopted by the 2020 Session of the Virginia General Assembly to curb balance billing.

Surprise billing – or balance billing – occurs when patients enrolled in managed care health insurance plans receive bills for more than their plan’s cost-sharing amounts directly from medical service providers who do not participate in a managed care plan’s network of providers – often referred to as “out-of-network” providers.

The new law may extend to individuals covered under private insurance they purchase on their own or through their employer. 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. Approximately 40 percent of individuals who receive their health insurance through their employer will have this protection under their fully insured plan. The remaining 60 percent have coverage through a self-funded ERISA or other arrangement where their employer provides benefits that are administered by a third party, which could be a health insurance company. Most of these health plans will have the option to become elective group health plans by choosing to provide these protections for their employees.

For the same protection to apply to individuals enrolled in elective group plans, the plans must choose to opt in by completing and submitting an online application to the State Corporation Commission’s (SCC) Bureau of Insurance (Bureau) at scc.virginia.gov. They have until December 2, 2020, to do so for protection to be effective on January 1, 2021. Applications submitted after that date may be effective at a later date. 

Plans that opt in will be listed on the Bureau’s website with other information provided by the Bureau regarding balancing billing. Health plans and healthcare providers can go to Balance Billing under the Regulated Industries tab on the Bureau’s website at scc.virginia.gov. Consumer information regarding balancing billing is available by going to Balance Billing Protections under the Consumers tab on the Bureau’s website.

Under the new law, health care facilities and other providers must provide patients with notifications that address how you are protected, when you can be balance billed, and what to do if you are billed too much. Health insurers regulated by the Bureau also must provide notification to enrollees regarding whether they are subject to balance billing and under what circumstances.

Individuals enrolled in plans covered under the new law or plans that have opted into the new law cannot be billed amounts above their cost-share responsibility by an out-of-network provider for emergency services or for certain non-emergency services – including surgery, anesthesia, pathology, radiology and hospitalist service – during a scheduled procedure at an in-network hospital or other health care facility.

If a consumer is treated by an out-of-network health care provider for services covered by the new law, the provider will submit the claim to the consumer’s insurer or health plan. The insurer or health plan will pay the provider a “commercially reasonable amount” that is based on payments for the same or similar services in a similar geographic area, thereby eliminating any balance payment by the consumer to the provider for services rendered.

The Bureau will make available on its website a data set that may be used to determine “commercially reasonable” payment amounts to providers. The data utilizes Virginia’s All-Payer Claims Database as an independent source of claims payment information.

As part of the claims resolution process under the balance billing law, the insurer and provider must first try to agree on a payment amount. If they cannot, one of the parties may request arbitration. Applications for individuals interested in becoming arbitrators will soon be available on the Bureau’s website along with instructions for applying. The Bureau’s website will offer a list of approved arbitrators from which parties entering arbitration may choose.

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.

For more information, contact the Virginia Bureau of Insurance toll-free at 1-877-310-6560 or visit its website at scc.virginia.gov. Questions related to the arbitrator application, requests to arbitrate, or questions regarding the self-funded opt-in process may be emailed to BBVA@scc.virginia.gov. Consumer questions and complaints about balance billing may be emailed to BureauofInsurance@scc.virginia.gov.

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Contact: Katha Treanor, 804-371-9141

Case Number INS-2020-00136

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SCC Urges Virginians to Prepare for Shopping for Health Insurance

OCT 29, 2020

RICHMOND – Many consumers will soon shop for health care coverage during the open enrollment period for the 2021 health insurance marketplace through HealthCare.gov. This open enrollment period for plans under the federal Affordable Care Act (ACA) runs from November 1 through December 15, 2020. After this date, consumers may only buy an ACA-compliant health insurance plan if special enrollment conditions apply to them.

Special enrollment periods (SEP) are available for people who may have recently lost their employer-sponsored health insurance coverage or have had a qualifying life event such as a household change. To learn more, visit HealthCare.gov's SEP page.

“For 2021 and again in 2022, enrollment and eligibility by Virginians will continue on HealthCare.gov, the federal health insurance platform. Virginia’s transition to a state-based system – the Virginia Health Benefit Exchange – will be ready by plan year 2023,” said Victoria Savoy, director of the Virginia Health Benefit Exchange.

The Virginia Exchange was created by the 2020 Virginia General Assembly to be operated as a new division within the State Corporation Commission (SCC). It will be an online marketplace where qualified individuals can shop for, compare and enroll in health insurance coverage. Additionally, the Virginia Exchange will create a small employer program where eligible employees of qualified small employers will be able to enroll in coverage.   

Whether you are thinking about changing plans or purchasing a new health insurance plan, the SCC encourages Virginians to review their coverage needs and thoroughly explore all their options. “Not all health plans are created alike, and some are not insurance,” said Virginia Insurance Commissioner Scott A. White. He encourages Virginians to fully understand the coverage, costs and protections before they sign up for any health plan. “Understand enrollment periods, what ACA-compliant plans must cover and where to turn for legitimate information. If you have questions, the Bureau of Insurance can help.”

Consumer protection laws govern some types of health coverage, such as plans purchased through an employer or through the health insurance marketplace. Other types of plans such as health care sharing ministries and discount plans might be less expensive than health insurance plans subject to the ACA, but they are not insurance and do not offer the same protections as ACA-compliant plans.

Short-term, limited-duration health insurance plans are not available through the health insurance marketplace, but they are regulated health insurance plans. While they may, in some cases, be less expensive than plans offered through the health insurance marketplace, they often cover less than ACA-compliant marketplace plans; may deny eligibility for coverage or exclude services because of pre-existing conditions, and may apply dollar limits on the amount they will pay.

Whether shopping for health insurance on or off the exchange, the Bureau of Insurance and the Virginia Health Benefit Exchange encourage Virginians to carefully consider what health care services you and your family will need before you sign up for any health insurance plan. Ask yourself:

  • Are anticipated services covered and are there any limits on coverage under each health care coverage option being considered? 
  • Are doctors and medications my family needs covered by the plan being considered? 
  • What are the monthly premiums and costs that coincide with using health services such as co-pays, co-insurance and deductibles? 

Especially during open enrollment, keep the following in mind:

  • In Virginia, HealthCare.gov is the official website to enroll in ACA plans.
  • For free help understanding your options, find an application assister (navigator and certified application counselor) at Coverva.org/assistance/.
  • Ask for details of any health plan in writing – including cost and coverage – and make sure you understand what you are purchasing.
  • Look for a disclosure indicating whether the health plan complies with the ACA.
  • The open enrollment period for the 2021 health insurance marketplace ends December 15, 2020. Anyone who contacts you to sell individual health insurance plans through an "enrollment period" outside of that is not selling an ACA-compliant policy.
  • Do not provide personal information or send money in response to unsolicited calls or emails.
  • To verify that an insurance agent, agency or company is licensed in Virginia, visit the Bureau’s website at scc.virginia.gov/boi/ConsumerInquiry/default.aspx.
  • Be wary of telemarketers from the "national enrollment center," "national healthcare center," or other official-sounding name. The marketplace will not call to sell you health insurance.

For more information, contact the Virginia Bureau of Insurance toll-free at 1-877-310-6560 or visit its website at scc.virginia.gov/pages/Insurance. Use the online comparison tool to compare plans. To learn more about the new Virginia Exchange, visit scc.virginia.gov/pages/Health-Benefit-Exchange-(6).

Free translation services are available. Call the Exchange hotline at 1-833-740-1364 or the Healthcare.gov hotline at 1-800-318-2596 for assistance.

 

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Contact: Katha Treanor, 804-371-9141

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