Children’s National is a hospital-based service provider. Provider visits include facility fees. The facility fees include costs for running the facility, such as supplies, equipment, exam rooms, educational resources, counseling and staff. It is separate from the cost of the medical provider.

Fees are determined based on the type of visit and the resources used during your visit. The exact facility fees cannot be calculated until after the medical services have been provided and your visit is finished.

Insurance Coverage of Facility Fees

Medicaid plans cover the full clinic facility fees. 

Commercial insurance plans may apply different benefits to outpatient clinic facility fees. This may change the out-of-pocket expense; for example, patients/families may be responsible for annual deductible requirements, co-insurance or co-pay amounts.

Financial Assistance maybe provided for income eligible families to cover up to 100% of out-of-pocket expense.

When you see a doctor or other healthcare provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a healthcare facility that isn’t in your health plan’s network.

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay, 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 annual out-of-pocket limit.

“Surprise billing” or “balance 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.

We encourage you to work with your insurance company to ensure you are accessing your highest level of benefits by using your in-network benefits. If you choose to use your out-of-network benefits for non-emergency services, you will be required to sign an additional consent.

• You are only responsible for paying your share of the cost (like the copayments, coinsurance and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
• Your health plan generally must:
  • Cover emergency services without requiring you to get approval for services in advance (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 deductible and out-of-pocket limit.

Virginia law prohibits out-of-network providers at in-network facilities from balance billing patients for emergency services at a hospital and certain non-emergency services. Virginia’s law applies to Virginia-regulated managed care plans, plans purchased on Healthcare.gov, and state employee benefit plans. 

Maryland law prohibits out-of-network providers from billing enrollees for amounts beyond in-network level of cost sharing. Maryland’s law applies to emergency services provided by out-of-network professionals, facilities and ambulance providers. Maryland’s law also