SEARCH SITE

VIRGINIA LAW PORTAL

SEARCHABLE DATABASES

ACROSS SESSIONS

Developed and maintained by the Division of Legislative Automated Systems.

2019 SESSION

19105200D
SENATE BILL NO. 1360
AMENDMENT IN THE NATURE OF A SUBSTITUTE
(Proposed by the Senate Committee on Commerce and Labor
on January 31, 2019)
(Patron Prior to Substitute--Senator Wagner)
A BILL to amend and reenact § 38.2-3445 of the Code of Virginia, relating to health benefit plans; balance billing for emergency services.

Be 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, or 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 for covered services, but may be required to pay (i) applicable deductibles, copayment, or coinsurance and (ii) costs deemed by the health carrier to be costs for non-covered 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) (a) the amount negotiated with in-network providers for the emergency service, or if more than one amount is negotiated, the median of these amounts average of the contracted commercial rates paid by the health carrier for the same emergency service in the geographic region, as defined by the Commission, where the emergency service was provided; (ii) (b) 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) (c) 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. The health carrier shall pay directly to an out-of-network health care provider the amount required to satisfy its obligation under subdivision A 4. The direct receipt by the out-of-network health care provider of payment from the health carrier for emergency services pursuant to this section shall preclude and prevent the out-of-network health care provider from billing or seeking payment from the covered person for any amounts other than (i) applicable deductibles, copayment, or coinsurance and (ii) costs deemed by the health carrier to be costs for non-covered services.

C. The final diagnosis rendered to a covered person that a medical condition did not pose a risk of resulting in (i) serious jeopardy to the mental or physical health of the individual, (ii) danger of serious impairment to bodily functions, (iii) serious dysfunction of any bodily organ or part, or (iv) in the case of a pregnant woman, serious jeopardy to the health of the fetus, shall not disqualify a covered person's condition from being an emergency medical condition.

D. An out-of-network provider may request the Commission's Bureau of Insurance to determine whether the amount of benefits that the health carrier has determined satisfies its obligation under subdivision A 4 does satisfy the health carrier's obligation to provide benefits in the amount equal to the greatest of the amounts described in clauses (a), (b), and (c) of subdivision A 4.