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2020 SESSION

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Senate Committee on Commerce and Labor
Subcommittee Health Insurance

Barker (Chair), Edwards, Obenshain

Date of Meeting: January 23, 2020
Time and Place: 5 PM / Senate Room 2, The Capitol

S.B. 172

Patron: Favola


Balance billing; emergency services. Provides that when a covered person receives covered emergency services from an out-of-network health care provider, the covered person is not required to pay the out-of-network provider any amount other than the applicable cost-sharing requirement. The measure deletes a provision that allows an out-of-network provider to charge an individual for the balance of the provider's billed amount after applying the amount the health carrier is required to pay for such services. The measure also establishes a fourth standard for calculating the health carrier's required payment to the out-of-network provider of the emergency services, which standard is (i) the regional average for commercial payments for such service if the provider is a health care professional or (ii) the fair market value for such services if the provider is a facility. This fourth standard is the amount the health carrier is obligated to pay to the out-of-network provider if the amount is greater than any of the other three standards, which are (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; (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; or (c) the amount that would be paid under Medicare for the emergency service. The measure requires the health carrier to pay the required amount, less applicable cost-sharing requirements, directly to the out-of-network health care provider of the emergency services. If such provider determines that the amount to be paid by the health carrier does not comply with the applicable requirements, the measure requires the provider and the health carrier to make a good faith effort to reach a resolution on the appropriate amount of the reimbursement and, if a resolution is not reached, authorizes either party to request the State Corporation Commission to review the disputed reimbursement amount and determine if the amount complies with applicable requirements. The measure also provides that final diagnosis rendered to a covered person who receives emergency services for a medical condition shall not be considered in the health carrier's determination of whether the medical condition was an emergency medical condition. The measure establishes the procedure by which the regional average for commercial payments for emergency services will be calculated by the nonprofit data services organization that compiles the Virginia All-Payer Claims Database. The measure also requires health carriers to makes reports to the Bureau of Insurance and directs the Bureau to provide reports to certain committees of the General Assembly.

A BILL to amend and reenact §§ 38.2-3438 and 38.2-3445 of the Code of Virginia, relating to health insurance; payment to out-of-network providers; emergency services.

20101733D

S.B. 226

Patron: Edwards


Virginia Health Benefit Exchange. Creates the Virginia Health Benefit Exchange, which will be established and operated by a new division within the State Corporation Commission (SCC). The Exchange shall facilitate the purchase and sale of qualified health plans and qualified dental plans to qualified individuals and qualified employers. The Exchange shall make qualified plans available to qualified individuals and qualified employers by July 1, 2023, unless the SCC postpones this date. The measure authorizes the SCC to review and approve accident and sickness insurance premium rates applicable to health benefit plans in the individual and small group markets and health benefit plans providing health insurance coverage in the individual market through certain non-employer group plans. The Exchange will be funded by assessments on health insurers offering plans in the Exchange. A health plan will not be required to cover any state-mandated health benefit if federal law does not require it to be covered as part of the essential benefits package. The essential health benefits are items and services included in the benchmark health insurance plan, which is the largest plan in the largest product in the Commonwealth's small group market as supplemented in order to provide coverage for the items and services within the statutory essential health benefits categories. The SCC may contract with other eligible entities and enter into memoranda of understanding with other agencies of the Commonwealth to carry out any of the functions of the Exchange, including agreements with other states or federal agencies to perform joint administrative functions. Such contracts are not subject to the Virginia Public Procurement Act (§ 2.2-4300 et seq.). The measure repeals a provision enacted in 2013 that prohibits an agent, employee, officer, or agency of the Commonwealth from taking any action to establish a health benefit exchange.

 

A BILL to amend and reenact §§ 38.2-4214, 38.2-4319, and 38.2-4509 of the Code of Virginia; to amend the Code of Virginia by adding in Title 38.2 a chapter numbered 65, consisting of sections numbered 38.2-6500 through 38.2-6515; and to repeal the second enactments of Chapters 670 and 679 of the Acts of Assembly of 2013, relating to the establishment and operation of a health benefit exchange for the Commonwealth; assessments.

20103715D

S.B. 243

Patron: Chase


Balance billing; emergency services. Provides that when a covered person receives covered emergency services from an out-of-network health care provider, the covered person is not required to pay the out-of-network provider any amount other than the applicable cost-sharing requirement. The measure deletes a provision that allows an out-of-network provider to charge an individual for the balance of the provider's billed amount after applying the amount the health carrier is required to pay for such services. The measure also establishes a fourth standard for calculating the health carrier's required payment to the out-of-network provider of the emergency services, which standard is (i) the regional average for commercial payments for such service if the provider is a health care professional or (ii) the fair market value for such services if the provider is a facility. This fourth standard is the amount the health carrier is obligated to pay to the out-of-network provider if the amount is greater than any of the other three standards, which are (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; (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; or (c) the amount that would be paid under Medicare for the emergency service. The measure requires the health carrier to pay the required amount, less applicable cost-sharing requirements, directly to the out-of-network health care provider of the emergency services. If such provider determines that the amount to be paid by the health carrier does not comply with the applicable requirements, the measure requires the provider and the health carrier to make a good faith effort to reach a resolution on the appropriate amount of the reimbursement and, if a resolution is not reached, authorizes either party to request the State Corporation Commission to review the disputed reimbursement amount and determine if the amount complies with applicable requirements. The measure also provides that final diagnosis rendered to a covered person who receives emergency services for a medical condition shall not be considered in the health carrier's determination of whether the medical condition was an emergency medical condition. The measure establishes the procedure by which the regional average for commercial payments for emergency services will be calculated by the nonprofit data services organization that compiles the Virginia All-Payer Claims Database. The measure also requires health carriers to makes reports to the Bureau of Insurance and directs the Bureau to provide reports to certain committees of the General Assembly.

 

A BILL to amend and reenact §§ 38.2-3438 and 38.2-3445 of the Code of Virginia, relating to health insurance; payment to out-of-network providers; emergency services.

20103706D

S.B. 251

Patron: Edwards

Pharmacy benefits managers; licensure and regulation. Provides that, beginning January 1, 2021, no person is authorized to provide pharmacy benefits management services or otherwise act as a pharmacy benefits manager without first obtaining a license from the State Corporation Commission. Such licenses are to be renewed annually. The bill also imposes recordkeeping and reporting requirements and provides that information or data acquired therefrom is considered proprietary and confidential and is not subject to the Virginia Freedom of Information Act.

A BILL to amend the Code of Virginia by adding in Chapter 34 of Title 38.2 an article numbered 9, consisting of sections numbered 38.2-3465, 38.2-3466, and 38.2-3467, relating to pharmacy benefits managers; licensure and regulation.

20101086D

S.B. 252

Patron: Edwards

Pharmacy benefit managers; licensure and regulation. Provides that, beginning January 1, 2021, no person is authorized to provide pharmacy benefit management services or otherwise act as a pharmacy benefit manager without first obtaining a license from the State Corporation Commission. Such licenses are to be renewed annually. The bill prohibits a pharmacy benefit manager from participating in spread pricing, defined in the bill, and provides that except for any agreed-upon administrative fee, all funds, including any rebates received by the pharmacy benefit manager in relation to providing pharmacy benefit management services for a carrier, will be distributed to the carrier.

A BILL to amend the Code of Virginia by adding in Chapter 34 of Title 38.2 an article numbered 9, consisting of sections numbered 38.2-3465 through 38.2-3467, relating to pharmacy benefit managers; licensure and regulation.

20101087D

S.B. 424

Patron: DeSteph


Health plans; calculation of enrollee's contribution to out-of-pocket maximum or cost-sharing requirement; rebates. Requires any carrier issuing a health plan in the Commonwealth to count the amount of any rebates received or to be received by the carrier or its pharmacy benefits manager in connection with the dispensing or administration of a prescription drug when calculating the enrollee's overall contribution to any out-of-pocket maximum or any cost-sharing requirement under the carrier's health plan.

A BILL to amend and reenact § 38.2-3407.20 of the Code of Virginia, relating to health plans; calculation of enrollee's contribution to out-of-pocket maximum or cost-sharing requirement; rebates.

20102635D

S.B. 522

Patron: McDougle


Balance billing; emergency and elective services. Requires health care facilities and health care providers to determine if providers scheduled to deliver elective services to a covered person are in the network of the covered person's managed care plan. The measure requires that when an elective service provider is determined to be out-of-network, in order for the covered person to assume financial responsibility for the out-of-network provider's charges, the health care facility or provider shall (i) inform the covered person of the out-of-network status of the provider, (ii) provide the covered person with the opportunity to be referred to an in-network provider, and (iii) prepare a document for signature by the covered person in which the covered person or his legal representative assumes financial responsibility for services performed by the out-of-network provider, and the covered person must sign the document described in clause (iii). The bill provides that such requirements will also apply to a health care provider in an office-based setting making a referral for elective radiology or pathology services.

The bill identifies post-stabilization services, performed in order to maintain or improve a person's stabilized condition related to an emergency medical condition, as emergency services if (a) the post-stabilization services are preapproved or related to preapproved services; (b) for an out-of-network facility, the health carrier does not effectuate transfer of the covered person within a reasonable amount of time after being notified by the facility of the covered person's need for post-stabilization services; (c) for an out-of-network health care professional, the facility is in-network; or (d) the out-of-network facility is unable to reasonably obtain health carrier information from the covered person prior to the furnishing of such services.

The measure 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 the fair market value, as defined in the bill, for the emergency services, less applicable cost-sharing requirements. The bill provides that direct payment from the health carrier to the out-of-network health care provider precludes the out-of-network health care provider from billing or seeking payment from the covered person for any other amount other than the applicable cost-sharing requirements. The bill removes from the determination of whether a medical condition is an emergency medical condition the final diagnosis rendered to the covered person.

A BILL to amend and reenact §§ 38.2-3438 and 38.2-3445 of the Code of Virginia and to amend the Code of Virginia by adding a section numbered 38.2-3445.2, relating to health insurance; payment of out-of-network providers.

20102243D

S.B. 573

Patron: Dunnavant

Health plans; calculation of enrollee's contribution to out-of-pocket maximum or cost-sharing requirement; rebates. Requires any carrier issuing a health plan in the Commonwealth to count the amount of any rebates received or to be received by the carrier or its pharmacy benefits manager in connection with the dispensing or administration of a prescription drug when calculating the enrollee's overall contribution to any out-of-pocket maximum or any cost-sharing requirement under the carrier's health plan.

A BILL to amend and reenact § 38.2-3407.20 of the Code of Virginia, relating to health plans; calculation of enrollee's contribution to out-of-pocket maximum or cost-sharing requirement; rebates.

20104282D

S.B. 598

Patron: Hanger


Virginia Health Benefit Exchange. Creates the Virginia Health Benefit Exchange, which will be established and operated by a new division within the State Corporation Commission (SCC). The Exchange shall facilitate the purchase and sale of qualified health plans and qualified dental plans to qualified individuals and qualified employers. The Exchange shall make qualified plans available to qualified individuals and qualified employers by July 1, 2023, unless the SCC postpones this date. The measure authorizes the SCC to review and approve accident and sickness insurance premium rates applicable to health benefit plans in the individual and small group markets and health benefit plans providing health insurance coverage in the individual market through certain non-employer group plans. The Exchange will be funded by assessments on health insurers offering plans in the Exchange. A health plan will not be required to cover any state-mandated health benefit if federal law does not require it to be covered as part of the essential benefits package. The essential health benefits are items and services included in the benchmark health insurance plan, which is the largest plan in the largest product in the Commonwealth's small group market as supplemented in order to provide coverage for the items and services within the statutory essential health benefits categories. The SCC may contract with other eligible entities and enter into memoranda of understanding with other agencies of the Commonwealth to carry out any of the functions of the Exchange, including agreements with other states or federal agencies to perform joint administrative functions. Such contracts are not subject to the Virginia Public Procurement Act (§ 2.2-4300 et seq.). The measure repeals a provision enacted in 2013 that prohibits an agent, employee, officer, or agency of the Commonwealth from taking any action to establish a health benefit exchange.

A BILL to amend and reenact §§ 38.2-4214, 38.2-4319, and 38.2-4509 of the Code of Virginia; to amend the Code of Virginia by adding in Title 38.2 a chapter numbered 65, consisting of sections numbered 38.2-6500 through 38.2-6515; and to repeal the second enactments of Chapters 670 and 679 of the Acts of Assembly of 2013, relating to the establishment and operation of a health benefit exchange for the Commonwealth; assessments.

20104272D

S.B. 732

Patron: McClellan


Virginia Health Benefit Exchange. Creates the Virginia Health Benefit Exchange, which will be established and operated by a new division within the State Corporation Commission (SCC). The Exchange shall facilitate the purchase and sale of qualified health plans and qualified dental plans to qualified individuals and qualified employers. The Exchange shall make qualified plans available to qualified individuals and qualified employers by July 1, 2023, unless the SCC postpones this date. The measure authorizes the SCC to review and approve accident and sickness insurance premium rates applicable to health benefit plans in the individual and small group markets and health benefit plans providing health insurance coverage in the individual market through certain non-employer group plans. The Exchange will be funded by assessments on health insurers. A health plan will not be required to cover any state-mandated health benefit if federal law does not require it to be covered as part of the essential benefits package. The essential health benefits are items and services included in the benchmark health insurance plan, which is the largest plan in the largest product in the Commonwealth's small group market as supplemented in order to provide coverage for the items and services within the statutory essential health benefits categories. The SCC may contract with other eligible entities and enter into memoranda of understanding with other agencies of the Commonwealth to carry out any of the functions of the Exchange, including agreements with other states or federal agencies to perform joint administrative functions. Such contracts are not subject to the Virginia Public Procurement Act (§ 2.2-4300 et seq.). The measure repeals a provision enacted in 2013 that prohibits an agent, employee, officer, or agency of the Commonwealth from taking any action to establish a health benefit exchange.

The measure requires the Department of Taxation to include on the appropriate individual tax return forms a checkoff box or similar mechanism for indicating whether the individual, or spouse in the case of a married taxpayer filing jointly, (i) is an uninsured individual at the time the return is filed and (ii) consents to the Department of Taxation providing the individual's tax information to the Department of Medical Assistance Services for purposes of determining the uninsured individual's or spouse's eligibility for medical assistance. Finally, the measure requires the Secretary of Health and Human Resources to convene a work group that includes representatives from the SCC, the Department of Medical Assistance Services, the Department of Social Services, and the Department of Taxation to develop systems, policies, and practices to leverage state income tax returns to facilitate the enrollment of eligible individuals in insurance affordability programs through the Virginia Health Benefit Exchange established in this measure. The Secretary shall report the work group's recommendations to the Governor and the General Assembly by September 15, 2020.

The provisions of the bill expire upon any ruling by the Supreme Court of the United States declaring unconstitutional, or action by the President or Congress that repeals or defunds, the provisions of the Patient Protection and Affordable Care Act in a manner that renders it impossible to perform the duties integral to the Virginia Health Benefit Exchange.

A BILL to amend and reenact §§ 38.2-4214, 38.2-4319, 38.2-4509, 58.1-3, and 58.1-341.1 of the Code of Virginia; to amend the Code of Virginia by adding in Title 38.2 a chapter numbered 65, consisting of sections numbered 38.2-6500 through 38.2-6516; and to repeal the second enactments of Chapters 670 and 679 of the Acts of Assembly of 2013, relating to the establishment and operation of a health benefit exchange for the Commonwealth; assessments; Department of Taxation; information sharing.

20105262D

S.B. 862

Patron: Pillion


Pharmacy benefits managers. Requires pharmacy benefits managers to register with the Commissioner of the Bureau of Insurance. The measure prohibits a carrier on its own or through its contracted pharmacy benefits manager or representative of a pharmacy benefits manager from (i) causing or knowingly permitting the use of any advertisement, promotion, solicitation, representation, proposal, or offer that is untrue, deceptive, or misleading; (ii) charge a pharmacist or pharmacy a fee related to the adjudication of a claim; (iii) engaging, with the express intent or purpose of driving out competition or financially injuring competitors, in a pattern or practice of reimbursing retail community pharmacies or pharmacists in the Commonwealth consistently less than the amount that the pharmacy benefits manager reimburses a pharmacy benefits manager affiliate for providing the same pharmacist services; (iv) collecting or requiring a pharmacy or pharmacist to collect from an insured a copayment for a prescription drug at the point of sale in an amount that exceeds the lesser of the contracted copayment amount, the amount an individual would pay for a prescription drug if that individual was paying cash, or the contracted amount for the drug; (v) reimbursing a pharmacy or pharmacist an amount less than the amount that the pharmacy benefits manager reimburses a pharmacy benefits manager affiliate for providing the same pharmacist services, calculated on a per-unit basis using the same generic product identifier or generic code number and reflecting all drug manufacturer's rebates, direct and indirect administrative fees, and costs and any remuneration; (vi) penalize or give an inducement to a covered individual for the purpose of having the covered individual use a specific retail community pharmacy, mail order pharmacy, or another network pharmacy provider that is a pharmacy benefits manager affiliate; (vii) prohibiting a pharmacist or pharmacy from offering and providing direct and limited delivery services including incidental mailing services, to an insured as an ancillary service of the pharmacy; (viii) charging a fee related to the adjudication of a claim without providing the cause for each adjustment or fee; (ix) steer a covered individual to a pharmacy in which the pharmacy benefit manager maintains an ownership interest or control without making a written disclosure to and receiving acknowledgment from the covered individual; or (x) penalizing or retaliating against a pharmacist or pharmacy for exercising rights provided by this measure. The measure also prohibits a carrier from (a) imposing provider accreditation standards or certification requirements inconsistent with, more stringent than, or in addition to requirements of the Virginia Board of Pharmacy or other state or federal entity; (b) including any mail order pharmacy or pharmacy benefits manager affiliate in calculating or determining network adequacy; or (c) conducting spread pricing in the Commonwealth. The measure requires each carrier to ensure that, before a particular drug is placed or continues to be placed on a Maximum Allowable Cost List, the drug meets certain standards, is available for purchase in the Commonwealth, and is not obsolete. The measure establishes requirements allowing network pharmacy providers to readily access the maximum allowable cost specific to that provider and requires Maximum Allowable Cost Lists to be updated every seven days. The measure requires the establishment of reasonable appeal procedures. The measure also imposes recordkeeping and reporting requirements and provides that information or data acquired therefrom is considered proprietary and confidential and is not subject to the Virginia Freedom of Information Act.

A BILL to amend the Code of Virginia by adding in Chapter 34 of Title 38.2 an article numbered 9, consisting of sections numbered 38.2-3465 through 38.2-3471, relating to regulation of pharmacy benefits managers.

20104480D