Non Contracted Plans

The best way for a member to check provider network status is to ask their plan.
You need to ask if the Vandalia Health provider is in-network with your plan. Your plan administrator telling you that you can “go to Vandalia Health” is insufficient and might result in you being personally responsible for unpaid out-of-network bills.

Health sharing plans are arrangements where a group of individuals come together to share medical expenses. These plans are not considered insurance and do not contract with Vandalia Health hospitals or healthcare facilities. They are not subject to the Affordable Care Act and therefore may not offer the same protections, such as minimum essential coverage or caps on out-of-pocket costs. They also are not bound by the same regulations as traditional insurance plans and can deem care an “unshared” expense that passes the cost along to the member as well as exclude pre-existing conditions.

A Vandalia Health hospital, facility, or physician that has no contract with your insurance company or health plan administrator — which could be a third-party administrator, or “TPA” (see below) — is referred to as “out-of-network.”

A third-party administrator delivers various services on behalf of health insurance plans — often self-insured health plans — which may include the design, launch, and management of the health plans. Some TPAs are now using unilateral repricing plans to set costs without provider input; however, because these plans do not contract with hospitals and facilities to provide their members care at in-network rates, their members are finding themselves out-of-network at many hospitals, including Vandalia Health.

No. While some unilateral repricing plans and health sharing plans say that plan members are free to go to any hospital or doctor, that does not mean that your care will be in-network. If your plan does not have a contract with a Vandalia Health hospital, facility, or doctor, your care will be out-of-network and you may be required to pay in advance for nonemergent care.

It is important to ask whether the specific Vandalia Health hospital, facility, or physician is “in-network.” You can reach out to your plan directly, using the number on your card. If your insurance is provided through your employer, you may also want to direct this question to your employee benefits representative.

Vandalia Health may require payment in advance for out-of-network nonemergent services. If a patient wants to schedule out-of-network care that is nonemergent — such as same-day surgery or advanced radiology — Vandalia Health will provide them with an estimate of these costs. We may ask for a deposit on the total amount due from the estimate. For out-of-network physician office visits, Vandalia Health may collect a self-pay pre-payment.

To ensure that you understand your financial responsibilities before scheduling services, you can visit our website at https://www.patientsimple.com/camc/estimates or call a Patient Financial Services representative at 304-388-5661. They will be able to give you an estimate for the care you are interested in scheduling. 

Vandalia Health does accept partial payments in the form of deposit amounts prior to service (typically 20 percent) or can arrange a payment plan for amounts due beyond the deposit, depending on the service that is being rendered. Required deposit amounts are due in full and in advance of services. If your service requires a deposit, a financial representative will contact you.

If the care provided ultimately costs more than the pre-payment amount, you will receive a bill for any additional amounts due. It will be your responsibility to pay the additional amounts in a timely manner, even if those additional services were not planned or were not included in the original estimate you received.

It will depend on your specific health plan. Some companies that use unilateral pricing offer plans that are out-of-network for Vandalia Health hospitals but in-network for Vandalia Health physicians in outpatient offices.

If your plan does not provide in-network access for office visits, Vandalia Health may collect a pre-payment for out-of-network physician office visits.

Yes. Pre-payment is not required for the following:

• Emergency care — All patients, regardless of insurance coverage or the lack of insurance, who present to any Vandalia Health Emergency Department for care will receive an appropriate medical screening examination and any stabilizing care necessary for their emergent condition
• Pediatric care — Care and services provided at Vandalia Health Women’s & Children’s Hospital

Even if pre-payment is waived, patients who receive out-of-network care at Vandalia Health will still be financially responsible for the costs of the out-of-network care they receive and will be balance-billed for any out-of-network amounts owed that their health insurance plan fails to pay.

In some cases, patients may be able to request that their health insurance plan pursue a single-case agreement with Vandalia Health for a specific scope of care.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other healthcare provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a healthcare facility that is not in your health plan's network.

"Out-of-network" means providers and facilities that have not signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan's deductible or annual out-of-pocket limit.

“Surprise billing" is an unexpected balance bill. This can happen when you cannot control who is involved in your care — like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

You are protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of- network provider or facility, the most they can bill you is your plan's in-network cost-sharing amount (such as copayments, coinsurance and deductibles). You cannot be balance billed for these emergency services. This includes services you may get after you are in stable condition unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan's in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist or intensivist services. These providers cannot balance bill you and may not ask you to give up your protections not to be balance billed. If you get other types of services at these in-network facilities, out-of-network providers cannot balance bill you, unless you give written consent and give up your protections.

You are never required to give up your protections from balance billing. You also are not required to get out-of-network care. You can choose a provider or facility in your plan's network.

When balance billing is not allowed, you also have these protections:

• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
• Generally, your health plan must:
  • Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
  • Cover emergency services by out-of-network providers.
  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
  • Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

Even though Vandalia Health may collect payment in advance for out-of-network services based on an estimate, patients may have an account balance following the out-of-network care and will receive a balance bill.

For more information about out-of-network products at Vandalia Health, please visit the Frequently Asked Questions page.

If you have additional questions, please call our customer service department at 304-388-7530.

One option to obtain healthcare insurance is from the government exchange at www.healthcare.gov. Subsidies may be available dependent on income. Vandalia Health’s West Virginia locations participate with both exchange plans offered in West Virginia (Highmark West Virginia and CareSource). Additionally, if you are concerned about the cost of your care, you can access more information about our financial assistance program online or reach out to our help line at 304-388-5432.