SB 172

Abstract

Health insurance; payment to out-of-network providers. Provides that when an enrollee receives emergency services from an out-of-network health care provider or receives out-of-network surgical or ancillary services at an in-network facility, the enrollee is not required to pay the out-of-network provider any amount other than the applicable cost-sharing requirement and such cost-sharing requirement cannot exceed the cost-sharing requirement that would apply if the services were provided in-network. The measure also provides that the health carrier's required payment to the out-of-network provider of the services is a commercially reasonable amount based on payments for the same or similar services provided in a similar geographic area. If such provider disputes the amount to be paid by the health carrier, the measure requires the provider and the health carrier to make a good faith effort to reach a resolution on the amount of the reimbursement. If the health carrier and the provider do not agree to a commercially reasonable payment and either party wants to take further action to resolve the dispute, then the measure requires the dispute will be resolved by arbitration. The measure establishes a framework for arbitration of such disputes which includes (i) a timeline for the proceedings, (ii) a method for choosing an arbitrator, (iii) required and optional factors for the arbitrator to consider, (iv) non-disclosure agreements, (v) reporting requirements, and (vi) an appeals process for appeals on certain procedural grounds. The measure requires the State Corporation Commission to contract with Virginia Health Information (VHI) to establish a data set and business protocols to provide health carriers, providers, and arbitrators with data to assist in determining commercially reasonable payments and resolving disputes. The measure requires the Commission, in consultation health carriers, providers, and consumers, to develop standard language for a notice of consumer rights regarding balance billing. The measure authorizes the Commission, the Board of Medicine, and the Commissioner of Health to levy fines and take action against a health carrier, health care practitioner, or medical care facility, respectively, for a pattern of violations of the prohibition against balance billing. Additionally, the measure prohibits a carrier or provider from initiating arbitration with such frequency as to indicate a general business practice. The measure provides that such provisions do not apply to an entity that provides or administers self-insured or self-funded plans; however, such entities may elect to be subject to such provisions. The measure authorizes the Commission to adopt rules and regulations governing the arbitration process. The measure has a delayed effective date of January 1, 2021. This bill incorporates SB 522 and is identical to HB 1251.

Health insurance; payment to out-of-network providers. Provides that when a covered person receives covered emergency services from an out-of-network health care provider or receives out-of-network services at an in-network facility, the covered person is not required to pay the out-of-network provider any amount other than the applicable cost-sharing requirement. The measure also provides that the health carrier's required payment to the out-of-network provider of the services is the usual and customary commercial payment. If such provider determines that the amount to be paid by the health carrier is not appropriate, the measure requires the provider and the health carrier to make a good faith effort to reach a resolution on the appropriate amount of the reimbursement and, if a resolution is not reached, authorizes either party to request to enter arbitration. The measure requires the State Corporation Commission to establish rules for an expedited arbitration process to settle disputes between providers and health carriers arising out of such disputes. Under the measure, the Commission is required to (i) establish a portal on its website for the submission of arbitration claims, (ii) contract with independent arbitrators to settle such disputes, (iii) ensure the arbitrators do not have a conflict of interest with the parties and have experience in health care billing, and (iv) maintain a list of such arbitrators on its website. The measure provides certain factors that an arbitrator is required to consider when settling such a disputed claim. The measure provides that provisions of the bill do not apply to an entity that provides or administers self-insured or self-funded plans; however, such entities may elect to be subject such provisions. The measure requires health carriers to make reports to the Bureau of Insurance and directs the Bureau to provide reports to certain committees of the General Assembly.

Balance billing; emergency services. Provides that whena covered person receives covered emergency services from an out-of-networkhealth care provider, the covered person is not required to pay theout-of-network provider any amount other than the applicable cost-sharingrequirement. The measure deletes a provision that allows an out-of-networkprovider to charge an individual for the balance of the provider's billedamount after applying the amount the health carrier is required to pay for suchservices. The measure also establishes a fourth standard for calculating thehealth carrier's required payment to the out-of-network provider of theemergency services, which standard is (i) the regional average for commercialpayments for such service if the provider is a health care professional or (ii)the fair market value for such services if the provider is a facility. Thisfourth standard is the amount the health carrier is obligated to pay to the out-of-networkprovider if the amount is greater than any of the other three standards, whichare (a) the amount negotiated with in-network providers for the emergencyservice or, if more than one amount is negotiated, the median of these amounts;(b) the amount for the emergency service calculated using the same method thehealth carrier generally uses to determine payments for out-of-networkservices, such as the usual, customary, and reasonable amount; or (c) theamount that would be paid under Medicare for the emergency service. The measurerequires the health carrier to pay the required amount, less applicablecost-sharing requirements, directly to the out-of-network health care providerof the emergency services. If such provider determines that the amount to bepaid by the health carrier does not comply with the applicable requirements,the measure requires the provider and the health carrier to make a good faitheffort to reach a resolution on the appropriate amount of the reimbursementand, if a resolution is not reached, authorizes either party to request theState Corporation Commission to review the disputed reimbursement amount anddetermine if the amount complies with applicable requirements. The measure alsoprovides that final diagnosis rendered to a covered person who receivesemergency services for a medical condition shall not be considered in thehealth carrier's determination of whether the medical condition was anemergency medical condition. The measure establishes the procedure by which theregional average for commercial payments for emergency services will becalculated by the nonprofit data services organization that compiles theVirginia All-Payer Claims Database. The measure also requires health carriersto makes reports to the Bureau of Insurance and directs the Bureau to providereports to certain committees of the General Assembly.