Is Valley in Your Health Plan?
|
Unraveling the Medicare mazeVMC's GoldenCare health and wellness program for seniors offers informative seminars to help you select your optimal Medicare plan and supplemental insurance. Learn about GoldenCare's other valuable benefits and download an application |
If we are contracted with your insurance company, we will bill you after your insurance company has processed your claim. Our billing statement lists relevant charges and clearly notes any payments we received from your insurance company.
If you do not have insurance coverage, you will need to make financial arrangements prior to receiving services at VMC; Please read about our Financial Assistance program options.
Notice to Medicare Beneficiaries
To our Medicare population, please review your Medicare benefits carefully. You are responsible to know your Medicare benefits and non-covered services. You will be financially responsible for any non-covered services. An example of a Medicare non-covered service would be any self-administered drugs provided to you during a hospital outpatient hospital visit. If you have Medicare supplemental insurance, VMC will also submit a bill to them for all services, including the non-covered Medicare charges. If no drug coverage exists, or the non-covered services are also denied by your supplemental Medicare plan, payment for those drugs will be your personal financial responsibility.
For a more complete explanation, please review the flyer, "Medicare--Am I Covered?"
Pre-authorization
Some procedures may require pre-authorization from your insurance company or making other financial arrangements in advance. Please review Pre-authorization Requirements and read our Guidelines for Preparing for Your Stay at VMC.
Billing
- About VMC hospital bills
- About VMC clinic bills
- About bills from contracted providers (e.g. other doctors, X-ray / imaging, anesthesiology, ambulance companies, labs, etc.)
- Special Note: For details on mental health service availability and coverage, please call 1.800.469.3979.
Know your rights under the Balance Billing Protection Act
| This notice applies to commercial plans (fully insured commercial, PEBB, SEBB and opted-in self-funded employer-sponsored) that are enrolled into the Balance Billing Protection Act (BBPA) for specific services. The BBPA does not apply to Medicare or Medicaid, which have other protections for enrollees. To confirm this notice applies to your health plan please contact your insurance carrier. |
Beginning January 1, 2020, Washington state law protects you from ‘surprise billing’ or ‘balance billing’ if you receive emergency care or are treated at an in-network hospital or outpatient surgical facility by an out-of-network provider.
What is ‘surprise billing’ or ‘balance billing’ and when does it happen?
Under your health plan, you’re responsible for certain cost-sharing amounts. This includes copayments, coinsurance and deductibles. You may have additional costs or be responsible for the entire bill if you see a provider or go to a facility that is not in your plan’s provider network.
Some providers and facilities have not signed a contract with your insurer. They are called ‘out-of- network’ providers or facilities. They can bill you the difference between what your insurer pays and the amount the provider or facility bills. This is called ‘surprise billing’ or ‘balance billing.’
Insurers are required to tell you, via their websites or on request, which providers, hospitals and facilities are in their networks. And hospitals, surgical facilities and providers must tell you which provider networks they participate in on their website or on request.
When you CANNOT be balance billed:
Emergency Services
The most you can be billed for emergency services is your plan’s in-network cost-sharing amount even if you receive services at an out-of-network hospital in Washington, Oregon or Idaho or from an out-of- network provider that works at the hospital. The provider and facility cannot balance bill you for emergency services.
Certain services at an In-Network Hospital or Outpatient Surgical Facility
When you receive surgery, anesthesia, pathology, radiology, laboratory, or hospitalist services from an out-of-network provider while you are at an in-network hospital or outpatient surgical facility, the most you can be billed is your in-network cost-sharing amount. These providers cannot balance bill you.
In situations when balance billing is not allowed, the following protections also apply:
- Your insurer will pay out-of-network providers and facilities directly. You are only responsible for paying your in-network cost-sharing.
- Your insurer must:
- Base your cost-sharing responsibility on what it would pay an in-network provider or facility in your area and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or certain out-of-network services (described above) toward your deductible and out-of-pocket limit.
- Your provider, hospital, or facility must refund any amount you overpay within 30 business days.
- A provider, hospital, or outpatient surgical facility cannot ask you to limit or give up these rights.
If you receive services from an out-of-network provider, hospital or facility in any OTHER situation, you may still be balance billed, or you may be responsible for the entire bill.
This law does not apply to all health plans. If you get your health insurance from your employer, the law might not protect you. Be sure to check your plan documents or contact your insurer for more information.
If you believe you’ve been wrongly billed, file a complaint with the Washington state Office of the Insurance Commissioner at www.insurance.wa.gov or call 1-800-562-6900.
Please see the column Health Carrier Networks below to see if Valley is a participating provider with your network in regards to the Balance Billing Protection Act.
| Health Plan | Health Carrier Networks | Does Valley Medical Center's hospital participate? |
Does Valley Medical Center's clinic network participate? |
| 6 Degrees Health | No - Not Contracted | No - Not Contracted |
| Aetna Health (including First Health/Conventry, excluding Aetna Whole Health) | Open Choice, Managed Choice, Elect Choice, Aetna Premier Care Network, Aexcel, all w & w/o Aetna Managed Pharmacy Network | Yes | Yes |
| Centivo | Cigna PPO Network, Embright Network | Yes | Yes |
| CIGNA (including former Great West and One Health plans) | WA PPO-PPA Direct Network, WA OAP Direct Network, WA PPO-PPA Direct Network w/National Pharmacy Network, WA OAP Direct w/National Pharmacy Network, Cigna LocalPlus of WA Network, Cigna Local Plus of WA w/National Pharmacy Network | Yes | Yes |
| Cigna Behavior Health Services | EverNorth | No | No |
| DSHS-Medicaid-Apple Health | Yes | Yes |
| DSHS Family Planning Only | Covers only contraception services in clinic; excludes all other medical services; excludes infants. | Covers only contraception services in clinic; excludes all other medical services; excludes infants. |
|
(DSHS) Medicaid Managed Care Plans |
|||
| Amerigroup | Yes | Yes | |
| Community Health Plan of Washington | Yes | No | |
| Coordinated Care (Centene) | Yes | Yes | |
| Molina Health Care | Yes | Yes | |
| United Healthcare Community Health Plan |
Yes | Yes | |
|
Exchange Products |
|||
| Molina Healthcare of Washington | Molina Choice, Constant Care and Core Care, Cascade Standard | Yes | Yes |
| Premera Heritage Signature | Preferred, Cascade | Yes | Yes |
| BridgeSpan Health Company | Bronze Care on Demand, Bronze Essential, Bronze HDHP, Cascade | Yes | Yes |
| United HealthCare | Bronze Value, Gold Value, Silver Advantage, Cascade | Yes | Yes |
| Regence Blue Shield | Individual and Family Network, Cascade, Bronze Care on Demand, Bronze Essential, Gold 2000 | Yes | Yes |
| Regence Blue Shield | Cascade Care East Side Health Network | No | No |
| Pacific Source (Accessed through First Choice Health Benefit) | Navigator, Cascade | Yes | Yes |
| Community Health Network | Cascade, Cascade Select | Yes | No Primary Care, Yes Specialty Care with referral |
| Coordinated Care (Ambetter) | Cascade Select, Cascade, Clear, Essential, Secure | No | No |
| Kaiser Foundation Health Plan of the Northwest | Cascade, WA Bronze, WA Gold, WA Silver | No | No |
| Federal Employees: Aetna Health, Alliance Health Plan, AWPU Health Plan, Blue Cross and Blue Shield, GEHA Benefit Plan, Mail Handlers, and PacifiCare | Yes | Yes |
| First Choice Health Network | First Choice Health Network | Yes | Yes |
| Kaiser Foundation Health Plan | Access PPO and Options Federal plans | Yes | Yes |
| Kaiser Foundation Health Plan | Summit PPO Network | Tier 2 Benefit | Tier 2 Benefit |
| Kaiser Foundation Health Plan | Core/HMO, Medicare Advantage, Elect PPO, Core Select and Connect/Virtual Plus | No | No |
| Labor & Industries | Yes | Yes |
| March Vision | Yes | Yes |
| Medicare | Yes | Yes |
|
Medicare Managed Care Plans |
|||
| Aetna Medicare Advantage | Yes | Yes | |
| Amerigroup Medicare Advantage | Yes | Yes | |
| Humana / Honor / Choice Care PPO/HMO |
Humana Medicare, Honor/Choice Care/PPO/HMO, Optum Care Network | Yes | Yes |
| Molina Medicare Complete Care | Select; D-SNP | Yes | Yes |
| Molina Medicare Choice Care | No | No | |
| Premera Medicare Advantage | Yes | Yes | |
| UnitedHealthcare Medicare MedAdvantage |
Yes | Yes | |
| Medicare Managed Care Plan Optum Care Network |
Yes | Yes | |
| Regence Blue Advantage HMO | Yes | Yes | |
| Regence Medicare Advantage PPO | Yes | Yes | |
| CHPW | Yes | No | |
| PacificSource Medicare | Yes | Yes | |
| WellCare Medicare HMO & PPO | Yes | Yes | |
| PEBB | State of Washington & other municipalities and government agencies | Yes | Yes |
| Premera Blue Cross | Global, Heritage, Heritage and Dental Choice, Heritage Prime, Heritage Signature, Heritage Signature and Dental Choice, Individual Signature, LifeWise Assurance Co., LifeWise Health Plan of WA Preferred |
Yes | Yes |
| Premera Blue Cross | LifeWise Primary, LifeWise Cascade Care | No | No |
| Private Health Care Systems / Multiplan | Yes | Yes |
| Regence Blue Shield | Participating, Preferred, Individual & Family Network, Real Value, UW Medicine AHN, High Performing Network (HPN) | Yes | Yes |
| SEBB | school districts state wide | Yes | Yes |
| Tricare | Yes | Yes |
| Triwest | Yes | Yes |
| Uniform Medical Plan | Yes | Yes |
| United Health Care/United Health Networks | Charter, Choice, Options, Signature Value, Select | Yes | Yes |
| United Health Care/United Health Networks | Navigate, Core | Yes | No |
* The contracted health plans listed above are subject to change.