FLOOR AMENDMENT (MCEACHIN) REJECTED BY HOUSE OF DELEGATES

1. Page 11, substitute, after line 23

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In addition to the recovery of fees by the Commissioner of Insurance, a person who was denied services by a utilization review entity may bring an action to recover damages for harm proximately caused by the failure to exercise reasonable care in denying such services by the utilization review entity or by its (i) employees, (ii) agents, or (iii) representatives who acted on its behalf and over whom it has a right to exercise influence or control or has actually exercised influence or control.

FLOOR AMENDMENTS (CRANWELL) REJECTED BY HOUSE OF DELEGATES

1. Page 1, substitute, Title, line 8, after Virginia

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; to amend the Code of Virginia by adding in Article 1 of Chapter 34 of Title 38.2 a section numbered 38.2-3407.17; and to repeal § 38.2-3407.12 of the Code of Virginia

2. Page 1, substitute, line 12, after reenacted

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and that the Code of Virginia is amended by adding in Article 1 of Chapter 34 of Title 38.2 a section numbered 38.2-3407.17

3. Page 6, substitute, after line 1

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§ 38.2-3407.17. Health care services; freedom of choice.

A. As used in this section:

"Carrier" means:

1. Any insurer licensed under this title proposing to offer or issue accident and sickness insurance policies that is subject to Chapter 34 (§ 38.2-3400 et seq.) of this title, including any health benefit program offered pursuant to a preferred provider policy or contract under § 38.2-3407 or covered services offered under a preferred provider subscription contract under § 38.2-4209;

2. Any nonstock corporation licensed under this title proposing to issue or deliver subscription contracts for one or more health services plans, medical or surgical services plans or hospital services plans that are subject to Chapter 42 (§ 38.2-4200 et seq.) of this title;

3. Any health maintenance organization licensed under this title that provides or arranges for the provision of one or more health care plans that are subject to Chapter 43 (§ 38.2-4300 et seq.) of this title;

4. Any nonstock corporation licensed under this title proposing to issue or deliver subscription contracts for one or more dental or optometric services plans which are subject to Chapter 45 (§ 38.2-4500 et seq.) of this title; and

5. Any other person licensed under this title that provides or arranges for the provision of health care coverage or benefits or health care plans or provider panels that are subject to regulation as the business of insurance under this title.

"Co-insurance" means the portion of the carrier's allowable charge for the covered item or service that is not paid by the carrier and for which the covered person is responsible.

"Co-payment" means the out-of-pocket charge other than co-insurance or a deductible for an item or service to be paid by the covered person to the provider toward the allowable charge as a condition of the receipt of specific health care items and services.

"Cost sharing arrangement" means any co-insurance, co-payment, deductible or similar arrangement imposed by the carrier on the covered person as a condition to or consequence of the receipt of covered health care services.

"Covered person" means an individual, whether a policyholder, subscriber, enrollee, or member of a managed care health insurance plan, who is entitled to health care services provided, arranged for, paid for or reimbursed pursuant to a managed care health insurance plan.

"Deductible" means the dollar amount of a covered item or service that the covered person is obligated to pay before benefits are payable under the carrier's policy or contract with the group contract holder.

"Health care services" means the furnishing of services, items or benefits to any individual for the purpose of preventing, alleviating, curing, or healing human illness, injury or physical disability.

"Managed care health insurance plan" or "MCHIP" means an arrangement for the delivery of health care in which a health carrier undertakes to provide, arrange for, pay for, or reimburse any of the costs of health care services for a covered person on a prepaid or insured basis that (i) contains one or more incentive arrangements, including any credentialing requirements intended to influence the cost or level of health care services between the health carrier and one or more providers with respect to the delivery of health care services, and (ii) requires or creates benefit payment differential incentives for covered persons to use providers that are directly or indirectly managed, owned, under contract with or employed by the health carrier. Any health maintenance organization as defined in § 38.2-4300 or health carrier that offers preferred provider contracts or policies as defined in § 38.2-3407 or preferred provider subscription contracts as defined in § 38.2-4209 shall be deemed to be offering one or more MCHIPs. A single managed care health insurance plan may encompass multiple products and multiple types of benefit payment differentials; however, a single managed care health insurance plan shall encompass only one provider panel or set of provider panels.

"Outside provider" means a provider that is not a member of the managed care health insurance plan's provider panel.

"Provider" means any physician, hospital or other person, including optometrists and clinical psychologists, that is licensed or otherwise authorized in the Commonwealth to deliver or furnish health care services.

"Provider panel" means the participating providers or referral providers, or network thereof, who have a contract, agreement or arrangement with a carrier, either directly or through an intermediary, and who have agreed to provide items or services to covered persons of the carrier's managed care health insurance plan.

B. Notwithstanding any provision of § 38.2-3407 to the contrary, no carrier operating a managed care health insurance plan in this Commonwealth shall prohibit any covered person receiving health care services furnished thereunder from selecting the provider of his choice to furnish health care services. This right of selection extends to and includes outside providers that have previously notified the carrier, by facsimile or otherwise, of their agreement to accept reimbursement for their health care services at the rates applicable to providers that are members of the MCHIP's provider panel, including any cost sharing arrangement consistently imposed by the carrier, as payment in full.

C. Each carrier shall permit prompt electronic or telephonic transmittal of the reimbursement agreement by the provider and ensure prompt verification to the provider of the terms of reimbursement. In no event shall any covered person receiving covered health care services from an outside provider that has submitted a reimbursement agreement be responsible for cost sharing arrangement amounts that may be charged by the outside provider in excess of the cost sharing arrangement amounts applicable to all members of the MCHIP's provider panel.

D. No such carrier shall impose upon any covered person receiving health care services furnished under any MCHIP:

1. Any cost sharing arrangement or condition that is not equally imposed upon all covered persons in the same benefit category, class or copayment level, whether or not such benefits are furnished by outside providers;

2. Any cost sharing arrangement or penalty that would affect or influence any covered person's choice of provider; or

3. Any reduction in allowable reimbursement for health care services related to utilization of outside providers.

E. No such carrier, with respect to any covered person receiving health care services furnished under any MCHIP, shall: (i) deny immediate access to electronic claims filing to an outside provider that has complied with subsection F of this section or (ii) require a covered person receiving health care services to make payment at point of service, except to the extent such conditions and penalties are similarly imposed on members of the MCHIP's provider panel.

F. Any provider who wishes to be covered by this section shall, if requested to do so in writing by a carrier, within thirty days of the provider's receipt of the request, execute and deliver to the carrier, the contract or agreement that the carrier requires all of the members of its provider panel to execute. Any provider who fails to timely execute and deliver such contract or agreement shall not be covered by this section with respect to that carrier unless and until the provider executes and delivers the contract or agreement.

G. The provisions of this section shall not be applicable to the provision of pharmacy benefits.

H. This section shall apply to policies, contracts, and plans delivered, issued for delivery, or renewed by carriers in this Commonwealth on or after July 1, 2000.

4. Page 6, substitute, line 31, after through

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38.2-3407.16

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38.2-3407.17

5. Page 6, substitute, line 45, after through

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38.2-3407.16

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38.2-3407.17

6. Page 7, substitute, line 17, after through

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38.2-3407.16

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38.2-3407.17

7. Page 7, substitute, line 42, after 38.2-3407.15,

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38.2-3407.17,

8. Page 12, substitute, after line 17

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2. That § 38.2-3407.12 of the Code of Virginia is repealed.