BILLING AND INSURANCE INFORMATION

Effective January 1, 2022, the No Surprises Act, which Congress passed as part of the Consolidated Appropriations Act of 2021, is designed to protect patients from surprise bills for emergency services at out-of-network facilities or for out-of-network providers at in-network facilities, holding them liable only for in-network cost-sharing amounts. The No Surprises Act also enables uninsured patients to receive a good faith estimate of the cost of care.

YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE MEDICAL BILLS
When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and or deductible.

What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care 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 health care facility that isn’t in your plan’s network.

“Out-of-network” means providers and facilities that haven’t 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 you 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 towards your plan’s deductible or annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t 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’re 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 can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balance 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, intensivist services. These providers can’t 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 in these in-network facilities, out-of-network providers can’t balance bill you unless you give written consent and give up your protections.

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

When balance billing isn’t allowed, you also have these protections:

• You’re only responsible for paying the share of the cost (like 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:

1. Cover emergency services without requiring you to get approval for services in advance (also known as “prior-authorization”). 
2. Cover emergency services by out-of-network providers.
3. Base what you owe the provide or facility (cost-sharing) on what it would pay in-network provider or facility and show that amount in your explanation of benefits.
4. Count any amount you pay for emergency services toward your in-network deductible and out-of-pocket limit.

If you think you have been wrongly billed, you may contact the U.S. Centers for Medicare and Medicaid Services (CMS) No Surprises Helpdesk at 1-800-985-3059 or visit https://www.cms.gov/nosurprises for more information about your rights under federal law.

Good Faith Estimates
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

• You have the right to receive a Good Faith Estimate for the total expected costs of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
• Make sure your health care provider gives you a Good Faith estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose for a Good Faith Estimate before you schedule an item or service
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059

Check your bill for online and pay-by-mail options. If you have lost your bill or do not have it with you, reference the addresses below:

Hospital Billing:
Account number on your bill begins with "H."
P.O. Box 1361
Williston, VT 05495
(802) 447-4500
Online at:  https://svhealthcare.patientsimple.com/guest/#/index

Physician Office Billing:
Account number on your bill ends in "A3744"
P.O. Box 5732
Belfast, ME 04915
(802) 440-4213
Online at: www.quickpayportal.com

If you don’t know whether your bill came from the hospital or from a physician’s office, call (802) 447-4500. With a few pieces of information, our billing specialists can provide the proper address.

SVMC bills all insurance companies. However, SVMC does not have contracts with all insurance companies. Without a contract some insurances will not pay SVMC directly. In these cases, patients are responsible for paying SVMC and collecting reimbursement from their insurance.

SVMC has contracts with the following insurance plans:

• Aetna PPO
• Blue Cross and Blue Shield of Vermont
• Blue Cross and Blue Shield of Massachusetts (Indemnity and PPO)
• BMC Healthnet Plan
• CDPHP
• CDPHP Medicaid
• CDPHP Exchange/Essential Plans
• CDPHP Medicare Advantage
• Cigna
• Fidelis Medicaid, Child Health Plus, HARP
• Fidelis Medicare Advantage
• Fidelis NY Exchange/Essential Plan
• Harvard Pilgrim Health Care (Commercial Plans)
• Health New England HMO, PPO, Medicare, Exchange
• Humana Medicare Advantage
• Martins Point
• MA Medicaid (Hospital Services only)
• Medicare
• MVP HMO/PPO/EPO
• MVP Medicare Advantage
• MVP Exchange/Essential Plan
• MVP Medicaid, Child Health Plus, HARP
• NY Medicaid
• Tufts HMO/PPO (Commercial plans)
• United Healthcare HMO/PPO (Commercial Plans)
• United Healthcare Medicare Solutions
• Vermont Medicaid
• Wellcare Medicaid
• Wellcare Medicare Advantage

SVMC understands that health care is expensive and that paying for it can be a financial burden. To help, SVMC has a financial assistance program available for patients. Financial assistance includes arranging payment plans and helping patients apply for charity care. For a financial screening to see what assistance you qualify for, call financial counseling at (802) 447-4500 8 a.m. – 4:30 p.m. weekdays.

Yes. If you are having difficulty paying an entire medical bill at once, you can set up a payment plan right away. The Billing Department can develop a plan that makes sense for you. Call (802) 447-4500 8 a.m. – 4:30 p.m. weekdays.

Southwestern Vermont Medical Center is committed to giving you high quality care no matter your insurance or financial situation.

WHAT IS PATIENT FINANCIAL ASSISTANCE (PFA)?

PFA can help you pay for the care you need. It covers most medically necessary care. It can help if you are uninsured or if you have insurance but need help paying your out-of-pocket costs.
Who can get Financial Assistance:
• You must be a resident of Vermont or the counties of Rensselaer (NY), Washington (NY) or Berkshire (MA). This includes students, non-citizens, and those who are unhoused. People who are employed in Vermont but live in another state also qualify. There is no residency restriction if the services provided were the result of a medical emergency.
• Your household income must be less than the limit.

INCOME LIMITS:

The amount you qualify for will be based on the size of your household and your household’s annual income. A patient’s household includes the patient, spouse, dependent, children and unmarried couples with a mutual child living together. For most people, your household size will be the same as the number of people listed on your tax return. You may qualify for partial or full PFA.

• Your household income must be less than 400% of the Federal Poverty Level.
• Your liquid assets must be less than 400% of the Federal Poverty Level. Liquid assets do not include primary residence, retirement accounts or pension plans.
• Catastrophic financial assistance is available if your income is less than 600% of the Federal Poverty Level and your medical bills exceed 20% of your household income.

For questions and help with your application, or if you need free language support, call SVMC Billing at (802) 447-4500 between 8 a.m. – 4:30 p.m. weekdays.

SVMC Financial Assistance Application
SVMC Financial Assistance Program Policy
SVMC FAP Plain Language Summary
SVMC Billing and Collection Policy

Programa de Asistencia Financiera de SVMC
SVMC Solicitud de ayuda económica
Política de elegibilidad del programa de ayuda

Yes. SVMC has certified assisters available to help Vermonters enroll in and maintain health coverage in person or virtually through Vermont Health Connect or Green Mountain Care. They can answer questions, walk you through an application, and (if you allow it) communicate directly with Vermont Health Connect on your behalf. Not living in Vermont? Our assisters can guide you to a similar agency in your state. Call 802-447-4502.