Health insurance coverage can come in many forms. Most of the health insurance coverage is through people’s employment. Those types of policies may be governed by the Federal ERISA Statute if certain requirements are met.
If the health insurance plan is not an ERISA plan, then the Virginia Anti-Subrogation Statute may apply. Va. Code § 38.2-3405. This bars subrogation by these plans. What that means is that when you have an accident and are injured and recover money the carrier cannot seek recovery of the amounts they have paid.
Any policy issued under the general umbrella of the federal employee’s health benefit plans contains a subrogation clause. Those subrogation clauses may bar any offset for attorneys’ fees in terms of any personal injury recovery.
Health Insurance Coverage – In Network Providers
Health insurance coverage may be broken down generally into in-network coverage and out of network coverage. In-network coverage simply means that the patient is going to a provider that is part of the network. That in-network provider is required to submit their bills directly to the carrier. The patient must provide the necessary information to the provider. Va Code 8.01-27.5B.
If the in-network provider does not submit its claim to the carrier, then the patient has no obligation to pay the provider. In addition in that case, the provider shall not benefit from any liens allowed by statute. Also the in-network provider is barred from recovering payment from any Med Pay policy.
If the in-network provider submits its claim in a timely fashion, then the carrier is obliged to pay pursuant to the terms of the plan. 8.01-27.5B
Health Insurance Coverage – Out of Network Providers
Some providers may be out of network. That simply means that they’re not in the plan. Those out of network providers cannot balance bill for most services provided. What that means is that they cannot bill more than what the carrier would have paid if that provider had been in-network.
That limitation applies to emergency services and also to non-emergency services performed at an in-network facility. There are some further limitations but those are the two general limitations. Va Code 38.2-3445.01
The obligation of the patient to the out of network provider is to pay the in-network cost-sharing requirement specified in the plan. That typically means that the patient would be obliged to pay what an in-network provider would have gotten. Va Code 38.2-3445.01
Under any circumstance, the amount paid to the out of network provider shall be commercially reasonable. That means that this out of network provider cannot simply jack up the cost because the patient is private pay. 38.2-3445.01.
Pursuant to 14 V.A.C. 5-405-30, a patient with a high deductible plan may be responsible for more.
Workers’ Compensation
Most health insurance plans bar coverage for workers’ compensation injuries. However if the patient has an on-the-job injury and the Workers’ Compensation Commission denies coverage for the injury, then the health insurance plan has to pick up the coverage. Va. Code § 38.2-3405
Health Insurance Coverage – Other types of coverage
As to coverage under Medicare, Medicaid see the posts on this site.
Call, or contact us for a free consult. Also for more info on health insurance coverage see the Wikipedia pages. Also see the post on this site dealing with contract issues.
