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2017 SESSION
17102378DBe it enacted by the General Assembly of Virginia:
1. That § 38.2-3407.3 of the Code of Virginia is amended and reenacted as follows:
§ 38.2-3407.3. Calculation of cost-sharing provisions.
A. An insurer, health services plan, or health
maintenance organization that issues an accident and sickness insurance policy
or contract pursuant to which the insured, subscriber or enrollee is required
to pay a specified percentage of the cost of covered services, shall calculate
such amount payable based upon an amount not to exceed the total amount
actually paid or payable to the provider of such services for the services
provided to the insured, subscriber, or enrollee. When there is no
amount actually paid or payable to the provider [ for such
by the insurer, health services plan, or health maintenance organization for
the ] services provided, the insurer, health services plan, or health
maintenance organization shall [ use such insurer's, health services
plan's, or health maintenance organization's pre-established allowed amount to
] calculate [ such the ] amount payable [ based
upon a fee schedule by the insured for such services ] . When
an insured, subscriber, or enrollee receives covered services outside
the insurer's, health services plan's, or health maintenance
organization's provider network, and such entity utilizes another insurer's,
health services plan's, or health maintenance organization's provider
network located outside the Commonwealth, such entity may satisfy the
obligation of this section by using the cost of services as reported by the
out-of-state insurer, health services plan, or health maintenance
organization when calculating the insured's, subscriber's, or enrollee's
percentage of the cost of covered services.
B. Any insurer, health services plan, or health maintenance organization failing to administer its contracts as set forth herein shall be deemed to have committed a knowing and willful violation of this section, and shall be punished as set forth in subsection A of § 38.2-218. Each claim payment found to have been calculated in noncompliance with this section shall be deemed a separate and distinct violation, and shall further be deemed a violation subject to subdivision D 1 c of § 38.2-218, permitting the Commission to require restitution in addition to any other penalties.