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2019 SESSION

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SB 1763 Health insurance; payment to out-of-network providers.

Introduced by: Glen H. Sturtevant, Jr. | all patrons    ...    notes | add to my profiles | history

SUMMARY AS PASSED SENATE:

Balance billing; emergency and elective services. Directs health carriers that provide individual or group health insurance that provide any benefits with respect to services rendered in an emergency department of a hospital to pay directly to an out-of-network health care provider an amount, less applicable cost-sharing requirements, that is 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 regional average for commercial payments for emergency services as of the date of treatment; (iii) the amount that would be paid under Medicare for an emergency service; and (iv) if out-of-network services are provided (a) by a health care professional, the regional average for commercial payments for such service, or (b) by a facility, the fair market value for such services. The bill removes from the determination of whether a medical condition is an emergency medical condition the final diagnosis rendered to the covered person. The bill requires a facility where a covered person receives scheduled elective services to post the required notice or inform the covered person of the required notice at the time of pre-admission or pre-registration. The bill also requires such a facility to inform the covered person or his legal representative of the names of all provider groups providing health care services at the facility, that consultation with the covered person's managed care plan is recommended to determine if the provider groups providing health care services at the facility are in-network providers, and that the covered person may be financially responsible for health care services performed by a provider that is not an in-network provider, in addition to any cost-sharing requirements. The measure includes an enactment providing that it shall not become effective unless an appropriation that addresses the anticipated effects of this act on the general fund is included in a general appropriation act passed in 2019 by the General Assembly that becomes law.

SUMMARY AS INTRODUCED:

Balance billing; emergency services. Directs health carriers that provide individual or group health insurance that provides any benefits with respect to services rendered in an emergency department of a hospital to pay directly to an out-of-network health care provider 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 regional average for commercial payments for emergency services as of the date of treatment; and (iii) the amount that would be paid under Medicare for an emergency service. The measure defines "regional average for commercial payments" as that fixed price that is determined and reported to the State Corporation Commission's Bureau of Insurance (the Bureau) by Virginia Health Information and adjusted annually by the Bureau in accordance with the United States Average Consumer Price Index (CPI) for medical care for the South region by considering the amounts paid to and accepted from health carriers or managed care plans in 2017 by similar providers for comparable out-of-network emergency services, as identified by Current Procedural Terminology codes, Health Care Common Procedure Coding System codes, diagnosis related group classifications, or revenue codes, in the community where the services were rendered, with the exclusion of amounts accepted by providers for patients covered by Medicare, TRICARE, or Medicaid. The bill removes from the determination of whether a medical condition is an "emergency medical condition" the final diagnosis rendered to the covered person. The measure provides that the State Corporation Commission shall resolve disputes between health care providers and health carriers regarding the appropriate reimbursement amount for such services rendered. The bill directs Virginia Health Information to submit a report to the Bureau establishing the regional average for commercial payments for emergency services based on 2017 data from the All-Payer Claims Database.