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2019 SESSION
19103091DBe it enacted by the General Assembly of Virginia:
1. That § 38.2-3445 of the Code of Virginia is amended and reenacted as follows:
§ 38.2-3445. Patient access to emergency services.
A. Notwithstanding any provision of § 38.2-3407.11, 38.2-4312.3, or any other section of this title to the contrary, if a health carrier providing individual or group health insurance coverage provides any benefits with respect to services in an emergency department of a hospital, the health carrier shall provide coverage for emergency services:
1. Without the need for any prior authorization determination, regardless of whether the emergency services are provided on an in-network or out-of-network basis;
2. Without regard to whether the health care provider furnishing the emergency services is a participating health care provider with respect to such services;
3. If such services are provided out-of-network, without imposing any administrative requirement or limitation on coverage that is more restrictive than the requirements or limitations that apply to such services received from an in-network provider;
4. If such services are provided out-of-network, any
cost-sharing requirement expressed as copayment amount or coinsurance rate
cannot exceed the cost-sharing requirement that would apply if such services
were provided in-network. However,
an An
individual may shall not be required to pay
the excess of the amount the out-of-network provider charges over the amount
the health carrier is required to pay under this section
except applicable deductibles, copayment amounts,
coinsurance rates, and
amounts charged for services that are
deemed by the health carrier to be noncovered services.
The health carrier complies with this requirement if the health carrier
provides benefits with respect to an emergency service in an amount equal to
the greatest of (i) the amount negotiated with in-network
providers for the emergency service, or if more than one amount is negotiated,
the median of these amounts; (ii) the amount for the emergency service
calculated using the same method the health carrier generally uses to determine
payments for out-of-network services, such as the usual, customary, and
reasonable amount; and (iii) the amount that would be paid under Medicare for
the emergency service.
A deductible may be imposed with respect to out-of-network emergency services only as a part of a deductible that generally applies to out-of-network benefits. If an out-of-pocket maximum generally applies to out-of-network benefits, that out-of-pocket maximum shall apply to out-of-network emergency services; and
5. Without regard to any term or condition of such coverage other than the exclusion of or coordination of benefits or an affiliation or waiting period.
B. In the event of a dispute between the out-of-network provider and the health carrier as to the appropriate reimbursement amount, either party may request the Commission's Bureau of Insurance to review the reimbursement amount and make a determination as to whether the reimbursement amount complies with subdivision A 4.