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2017 SESSION
17105547DBe it enacted by the General Assembly of Virginia:
1. That §§ 38.2-3407.3 and 38.2-3407.13:2 of the Code of Virginia are 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 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 the amount payable 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.
§ 38.2-3407.13:2. Claims paid to insureds for services from nonparticipating physicians.
When an insurer, health services plan or health maintenance
organization follows a policy of sending its payment to the insured, subscriber
or enrollee for a claim for services received from a nonparticipating physician
or osteopath, the insurer, health services plan or health maintenance
organization shall: (i) include language in the certificate or evidence
of coverage of the insured, subscriber or enrollee that notifies the insured,
subscriber or enrollee of the responsibility to apply the plan payment to the
claim from such nonparticipating provider, (ii) include this language with any
such payment sent to the insured, subscriber or enrollee, and (iii)
include the name and any last known address of the nonparticipating provider on
the explanation of benefits statement, and (iv) make the payment by a check
payable jointly to both the insured, subscriber or enrollee and the
nonparticipating physician or osteopath.