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ACROSS SESSIONS
- Subject Index: Since 1995
- Bills & Resolutions: Since 1994
- Summaries: Since 1994
Developed and maintained by the Division of Legislative Automated Systems.
1995 SESSION
LD2084364Patrons--Morgan, Abbitt, Armstrong, Bennett, Bloxom, Callahan, Cooper, Cox, Cranwell, Darner, Davies, Dickinson, Dudley, Hargrove, Jackson, Johnson, Jones, J.C., Keating, Moore, Nixon, Parrish, Plum, Putney, Reynolds, Rhodes, Robinson, Ruff, Stump, Thomas, Van Yahres and Way; Senators: Cross, Holland, R.J., Lucas, Saslaw, Trumbo and Waddell
Be it enacted by the General Assembly of Virginia:
1. That §§ 38.2-3407.7, 38.2-3407.8, 38.2-4209.1, 38.2-4209.2, 38.2-4312.1, and 38.2-4312.2 of the Code of Virginia are amended and reenacted as follows:
§ 38.2-3407.7. Pharmacies; freedom of choice.
A. Notwithstanding any provision of § 38.2-3407 to the contrary, no insurer
proposing to issue preferred provider policies or contracts shall prohibit
any person receiving pharmacy benefits furnished thereunder from selecting,
without limitation, the pharmacy of his choice to furnish such benefits. This
right of selection extends to and includes pharmacies that are nonpreferred
providers and that agree have previously notified the
insurer, by facsimile or otherwise, of their agreement to accept
reimbursement for their services at rates applicable to pharmacies that are
preferred providers, including any copayment consistently imposed by the
insurer, as payment in full. Each insurer shall establish a system to permit
prompt electronic or telephonic transmittal of the reimbursement agreement by
the pharmacy and to ensure prompt verification to the pharmacy of the terms
of reimbursement. In no event shall any person receiving a covered pharmacy
benefit from a nonpreferred provider which has submitted a reimbursement
agreement be responsible for amounts that may be charged by the nonpreferred
provider in excess of the copayment and the insurer’s reimbursement
applicable to all of its preferred pharmacy providers.
B. No such insurer shall impose upon any person receiving pharmaceutical benefits furnished under any such policy or contract:
1. Any copayment, fee or condition that is not equally imposed upon all individuals in the same benefit category, class or copayment level, whether or not such benefits are furnished by pharmacists who are nonpreferred providers;
2. Any monetary penalty that would affect or influence any such person's choice of pharmacy; or
3. Any reduction in allowable reimbursement for pharmacy services related to utilization of pharmacists who are nonpreferred providers.
C. For purposes of this section, a prohibited condition or penalty shall include, without limitation: (i) denying immediate access to electronic claims filing to a pharmacy which is a nonpreferred provider and which has complied with subsection D below; or (ii) requiring a person receiving pharmacy benefits to make payment at point of service except to the extent such conditions and penalties are similarly imposed on preferred providers.
D. Any pharmacy which wishes to be covered by this section shall, if requested to do so in writing by an insurer, within thirty days of the pharmacy’s receipt of the request, execute and deliver to the insurer the direct service agreement or preferred provider agreement which the insurer requires all of its preferred providers of pharmacy benefits to execute. Any pharmacy which fails to timely execute and deliver such agreement shall not be covered by this section with respect to that insurer unless and until the pharmacy executes and delivers the agreement.
C. E. The Commission shall have no jurisdiction to
adjudicate controversies arising out of this section.
§ 38.2-3407.8. Ancillary service providers; freedom of choice.
A. Notwithstanding any provision of § 38.2-3407 to the contrary, no insurer
proposing to issue preferred provider policies or contracts shall prohibit
any person receiving ancillary service benefits furnished thereunder from
selecting, without limitation, the ancillary service provider of his choice
to furnish such benefits. This right of selection extends to and includes
ancillary service providers that are nonpreferred providers and that
agree have previously notified the insurer, by facsimile or
otherwise, of their agreement to accept reimbursement for their
services at rates applicable to ancillary service providers that are
preferred providers, including any copayment consistently imposed by the
insurer, as payment in full. Each insurer shall establish a system to permit
prompt electronic or telephonic transmittal of the reimbursement agreement by
the ancillary service provider and to ensure prompt verification to the
provider of the terms of reimbursement. In no event shall any person
receiving a covered ancillary service benefit from a nonpreferred provider
which has submitted a reimbursement agreement be responsible for amounts that
may be charged by the nonpreferred provider in excess of the copayment and
the insurer’s reimbursement applicable to all of its preferred
providers.
B. No such insurer shall impose upon any person receiving ancillary service benefits furnished under any such policy or contract:
1. Any copayment, fee or condition that is not equally imposed upon all individuals in the same benefit category, class or copayment level, whether or not such benefits are furnished by ancillary service providers who are nonpreferred providers;
2. Any monetary penalty that would affect or influence any such person's choice of ancillary service provider; or
3. Any reduction in allowable reimbursement for ancillary services related to utilization of ancillary service providers who are nonpreferred providers.
C. For the purposes of this section:
1. "Ancillary services" means those only the following
services required to support, facilitate or otherwise enhance medical
care and treatment.: Such services include, but
are not limited to, (i) the furnishing of medical equipment
required for therapeutic purposes or life support; (ii) home health care
and home infusion services delivered or arranged by a licensed home health
agency or pharmacy; (iii) magnetic resonance imaging, computed tomography,
ultrasound, mammography and diagnostic x-ray services; and (iv) independent
clinical laboratory services delivered outside of a physician’s office;
provided that, nothing herein shall excuse compliance with § 54.1-2411 of the
Practitioner Self-Referral Act.
2. "Ancillary service provider" and "ancillary service providers" mean a person or persons providing ancillary services.
D. Any ancillary service provider which wishes to be covered by this section shall, if requested to do so in writing by an insurer, within thirty days of the ancillary service provider’s receipt of the request, execute and deliver to the insurer the direct service agreement or preferred provider agreement which the insurer requires all of its preferred providers of such ancillary services to execute. Any ancillary service provider which fails to timely execute and deliver such agreement shall not be covered by this section with respect to that insurer unless and until the ancillary service provider executes and delivers the agreement.
D. E. The Commission shall have no jurisdiction to
adjudicate controversies arising out of this section.
§ 38.2-4209.1. Pharmacies; freedom of choice.
A. Notwithstanding any provision of § 38.2-4209, no corporation providing
preferred provider subscription contracts shall prohibit any person receiving
pharmaceutical benefits thereunder from selecting, without limitation, the
pharmacy of his choice to furnish such benefits. This right of selection
extends to and includes pharmacies that are nonpreferred providers and that
agree have previously notified the corporation, by facsimile
or otherwise, of their agreement to accept reimbursement for their
services at rates applicable to pharmacies that are preferred providers,
including any copayment consistently imposed by the corporation, as payment
in full. Each corporation shall establish a system to permit prompt
electronic or telephonic transmittal of the reimbursement agreement by the
pharmacy and to ensure payment verification to the pharmacy of the terms of
reimbursement. In no event shall any person receiving a covered pharmacy
benefit from a nonpreferred provider which has submitted a reimbursement
agreement be responsible for amounts that may be charged by the nonpreferred
provider in excess of the copayment and the corporation’s reimbursement
applicable to all of its preferred pharmacy providers.
B. No such corporation shall impose upon any person receiving pharmaceutical benefits furnished under any such contract:
1. Any copayment, fee or condition that is not equally imposed upon all individuals in the same benefit category, class or copayment level, whether or not such benefits are furnished by pharmacists who are nonpreferred providers;
2. Any monetary penalty that would affect or influence any such person's choice of pharmacy; or
3. Any reduction in allowable reimbursement for pharmacy services related to utilization of pharmacists who are nonpreferred providers.
C. For purposes of this section, a prohibited condition or penalty shall include, without limitation: (i) denying immediate access to electronic claims filing to a pharmacy which is a nonpreferred provider and which has complied with subsection D below or (ii) requiring a person receiving pharmacy benefits to make payment at point of service, except to the extent such conditions and penalties are similarly imposed on preferred providers.
D. Any pharmacy which wishes to be covered by this section shall, if requested to do so in writing by a corporation, within thirty days of the pharmacy’s receipt of the request, execute and deliver to the corporation the direct service agreement or preferred provider agreement which the corporation requires all of its preferred providers of pharmacy benefits to execute. Any pharmacy which fails to timely execute and deliver such agreement shall not be covered by this section with respect to that corporation unless and until the pharmacy executes and delivers the agreement.
C. E. The Commission shall have no jurisdiction to
adjudicate controversies arising out of this section.
§ 38.2-4209.2. Ancillary service providers; freedom of choice.
A. Notwithstanding any provision of § 38.2-4209, no corporation providing
preferred provider subscription contracts shall prohibit any person receiving
ancillary service benefits thereunder from selecting, without limitation, the
ancillary service provider of his choice to furnish such benefits. This right
of selection extends to and includes ancillary service providers that are
nonpreferred providers and that agree have previously
notified the corporation, by facsimile or otherwise, of their agreement
to accept reimbursement for their services at rates applicable to ancillary
service providers that are preferred providers, including any copayment
consistently imposed by the corporation, as payment in full. Each
corporation shall establish a system to permit prompt electronic or
telephonic transmittal of the reimbursement agreement by the ancillary
service provider and to ensure prompt verification to the provider of the
terms of reimbursement. In no event shall any person receiving a covered
ancillary service benefit from a nonpreferred provider which has submitted a
reimbursement agreement be responsible for amounts that may be charged by the
nonpreferred provider in excess of the copayment and the corporation’s
reimbursement applicable to all of its preferred providers.
B. No such corporation shall impose upon any person receiving ancillary service benefits furnished under any such contract:
1. Any copayment, fee or condition that is not equally imposed upon all individuals in the same benefit category, class or copayment level, whether or not such benefits are furnished by ancillary service providers who are nonpreferred providers;
2. Any monetary penalty that would affect or influence any such person's choice of ancillary service provider; or
3. Any reduction in allowable reimbursement for ancillary services related to utilization of ancillary service providers who are nonpreferred providers.
C. For the purposes of this section:
1. "Ancillary services" means those only the following
services required to support, facilitate or otherwise enhance medical
care and treatment. Such services include, but are not limited to,
: (i) the furnishing of medical equipment
required for therapeutic purposes or life support; (ii) home health care
and home infusion services delivered or arranged by a licensed home health
agency or pharmacy; (iii) magnetic resonance imaging, computed tomography,
ultrasound, mammography and diagnostic x-ray services; and (iv) independent
clinical laboratory services delivered outside of a physician’s office;
provided that, nothing herein shall excuse compliance with § 54.1-2411 of the
Practitioner Self-Referral Act.
2. "Ancillary service provider" and "ancillary service providers" mean a person or persons providing ancillary services.
D. Any ancillary service provider which wishes to be covered by this section shall, if requested to do so in writing by such a corporation, within thirty days of the ancillary service provider’s receipt of the request, execute and deliver to the corporation the direct service agreement or preferred provider agreement which the corporation requires all of its preferred providers of such ancillary services to execute. Any ancillary service provider which fails timely to execute and deliver such agreement shall not be covered by this section with respect to that corporation unless and until the ancillary service provider executes and delivers the agreement.
D. E. The Commission shall have no jurisdiction to
adjudicate controversies arising out of this section.
§ 38.2-4312.1. Pharmacies; freedom of choice.
A. Notwithstanding any other provision in this chapter, no health
maintenance organization providing health care plans shall prohibit any
person receiving pharmaceutical benefits thereunder from selecting, without
limitation, the pharmacy of his choice to furnish such benefits. This right
of selection extends to and includes pharmacies that are not participating
providers under any such health care plan and that agree have
previously notified the health maintenance organization, by facsimile or
otherwise, of their agreement to accept reimbursement for their
services at rates applicable to pharmacies that are participating
providers, including any copayment consistently imposed by the plan, as
payment in full. Each health maintenance organization shall establish a
system to permit prompt electronic or telephonic transmittal of the
reimbursement agreement by the pharmacy and to ensure prompt verification to
the pharmacy of the terms of reimbursement. In no event shall any person
receiving a covered pharmacy benefit from a nonparticipating provider which
has submitted a reimbursement agreement be responsible for amounts that may
be charged by the nonparticipating provider in excess of the copayment and
the health maintenance organization’s reimbursement applicable to all of
its participating pharmacy providers.
B. No such health maintenance organization shall impose upon any person receiving pharmaceutical benefits furnished under any such health care plan:
1. Any copayment, fee or condition that is not equally imposed upon all individuals in the same benefit category, class or copayment level, whether or not such benefits are furnished by pharmacists who are not participating providers;
2. Any monetary penalty that would affect or influence any such person's choice of pharmacy; or
3. Any reduction in allowable reimbursement for pharmacy services related to utilization of pharmacists who are not participating providers.
C. For purposes of this section, a prohibited condition or penalty shall include, without limitation: (i) denying immediate access to electronic claims filing to a pharmacy which is a nonparticipating provider and which has complied with subsection E below or (ii) requiring a person receiving pharmacy benefits to make payment at point of service, except to the extent such conditions and penalties are similarly imposed on participating providers.
C. D. The provisions of this section are not
applicable to any health care plan whose terms require exclusive utilization
of pharmacies wholly owned and operated by the health maintenance
organization providing the health care plan.
E. Any pharmacy which wishes to be covered by this section shall, if requested to do so in writing by a health maintenance organization, within thirty days of the pharmacy’s receipt of the request, execute and deliver to the health maintenance organization the direct service agreement or participating provider agreement which the health maintenance organization requires all of its participating providers of pharmacy benefits to execute. Any pharmacy which fails to timely execute and deliver such agreement shall not be covered by this section with respect to that health maintenance organization unless and until the pharmacy executes and delivers the agreement.
D. F. The Commission shall have no jurisdiction to
adjudicate controversies arising out of this section.
§ 38.2-4312.2. Ancillary service providers; freedom of choice.
A. Notwithstanding any other provision in this chapter, no health
maintenance organization providing health care plans shall prohibit any
person receiving ancillary service benefits thereunder from selecting,
without limitation, the ancillary service provider of his choice to furnish
such benefits. This right of selection extends to and includes ancillary
service providers that are not participating providers under any such health
care plan and that agree have previously notified the health
maintenance organization, by facsimile or otherwise, of their agreement
to accept reimbursement for their services at rates applicable to ancillary
service providers that are participating providers, including any
copayment consistently imposed by the plan, as payment in full. Each health
maintenance organization shall establish a system to permit prompt electronic
or telephonic transmittal of the reimbursement agreement by the ancillary
service provider and to ensure prompt verification to the provider of the
terms of reimbursement. In no event shall any person receiving a covered
ancillary service benefit from a nonparticipating provider which has
submitted a reimbursement agreement be responsible for amounts that may be
charged by the nonparticipating provider in excess of the copayment and the
health maintenance organization’s reimbursement applicable to all of its
participating providers.
B. No such health maintenance organization shall impose upon any person receiving ancillary services benefits furnished under any such health care plan:
1. Any copayment, fee or condition that is not equally imposed upon all individuals in the same benefit category, class or copayment level, whether or not such benefits are furnished by ancillary service providers who are not participating providers;
2. Any monetary penalty that would affect or influence any such person's choice of ancillary service provider; or
3. Any reduction in allowable reimbursement for ancillary services related to utilization of ancillary service providers who are not participating providers.
C. For the purposes of this section:
1. "Ancillary services" means those only the following
services required to support, facilitate or otherwise enhance medical
care and treatment. Such services include, but are not limited to,
: (i) the furnishing of medical equipment required for
therapeutic purposes or life support; (ii) home health care and home
infusion services delivered or arranged by a licensed home health agency or
pharmacy; (iii) magnetic resonance imaging, computed tomography, ultrasound,
mammography and diagnostic x-ray services; and (iv) independent clinical
laboratory services delivered outside of a physician’s office; provided
that, nothing herein shall excuse compliance with § 54.1-2411 of the
Practitioner Self-Referral Act.
2. "Ancillary service provider" and "ancillary service providers" mean a person or persons providing ancillary services.
D. Any ancillary service provider which wishes to be covered by this section shall, if requested to do so in writing by a health maintenance organization, within thirty days of the ancillary service provider’s receipt of the request, execute and deliver to the health maintenance organization the direct service agreement or participating provider agreement which the health maintenance organization requires all of its participating providers of such ancillary services to execute. Any ancillary service provider which fails to timely execute and deliver such agreement shall not be covered by this section with respect to that health maintenance organization unless and until the ancillary service provider executes and delivers the agreement.
D. E. The provisions of this section are not
applicable to any health care plan whose terms require exclusive utilization
of ancillary service providers wholly owned and operated by the health
maintenance organization providing the health care plan.
E. F. The Commission shall have no jurisdiction to
adjudicate controversies arising out of this section.