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2016 SESSION

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16100576D
SENATE BILL NO. 752 Offered January 22, 2016 A BILL to amend the Code of Virginia by adding a section numbered 38.2-3407.15:4, relating to health insurance; carrier business practices; refusal of participating providers to accept enrollees as patients. ---------- Patron-- Surovell ---------- Referred to Committee on Commerce and Labor ----------

Be it enacted by the General Assembly of Virginia:

1. That the Code of Virginia is amended by adding a section numbered 38.2-3407.15:4 as follows:

§ 38.2-3407.15:4. Carrier contracts; required provisions regarding refusal to accept patients.

A. As used in this section, unless the context requires a different meaning:

"Carrier" and "provider contract" have same meaning ascribed thereto in subsection A of § 38.2-3407.15.

"Covered service" means a health care service that a participating provider is authorized to provide and has agreed to provide to enrollees pursuant to the terms of a provider contract.

"Enrollee," "provider," and "provider panel" have same meaning ascribed thereto in subsection A of § 38.2-3407.10.

"Mechanism of the injury" means the circumstances under which an enrollee sustained an injury, which circumstances include, by way of illustration, whether the injury results from an accident for which a tortfeasor may be liable.

"Participating provider" means a provider who, under the terms of a provider contract with a carrier or with its contracting agent, has agreed to provide health care services to enrollees with an expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly from the carrier.

B. Any provider contract between a carrier and a participating provider, or its contracting agent, shall contain specific provisions that prohibit the participating provider from refusing or declining, in whole or in part on the basis of the mechanism of the injury sustained by an enrollee, to accept an injured enrollee as a patient or to provide covered services to an injured enrollee.

C. The Commission shall have no jurisdiction to adjudicate individual controversies arising out of this section.

D. This section shall apply with respect to any contract between a carrier and a participating provider, or its contracting agent, that is entered into, amended, extended, or renewed on or after January 1, 2017.

E. Notwithstanding any law to the contrary, the provisions of this section shall not apply to:

1. Coverages issued pursuant to Title XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq. (Medicare), Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. (Medicaid), Title XXI of the Social Security Act, 42 U.S.C. § 1397aa et seq. (CHIP), 5 U.S.C. § 8901 et seq. (federal employees), or 10 U.S.C. § 1071 et seq. (TRICARE);

2. The state employee health insurance plan established pursuant to § 2.2-2818;

3. Credit or disability insurance, long-term care insurance, TRICARE supplement, Medicare supplement, or workers' compensation coverages; or

4. Any dental services plan or optometric services plan as those terms are defined in § 38.2-4501.