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2020 SESSION

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HB 1251 Health insurance; definitions, payment to out-of-network providers, emergency services.

Introduced by: Luke E. Torian | all patrons    ...    notes | add to my profiles | history

SUMMARY AS PASSED:

Health insurance; payment to out-of-network providers. Provides that when an enrollee receives emergency services from an out-of-network health care provider or receives out-of-network surgical or ancillary services at an in-network facility, the enrollee is not required to pay the out-of-network provider any amount other than the applicable cost-sharing requirement and such cost-sharing requirement cannot exceed the cost-sharing requirement that would apply if the services were provided in-network. The measure also provides that the health carrier's required payment to the out-of-network provider of the services is a commercially reasonable amount based on payments for the same or similar services provided in a similar geographic area. If such provider disputes the amount to be paid by the health carrier, the measure requires the provider and the health carrier to make a good faith effort to reach a resolution on the amount of the reimbursement. If the health carrier and the provider do not agree to a commercially reasonable payment and either party wants to take further action to resolve the dispute, then the measure requires the dispute will be resolved by arbitration. The measure establishes a framework for arbitration of such disputes that includes (i) a timeline for the proceedings, (ii) a method for choosing an arbitrator, (iii) required and optional factors for the arbitrator to consider, (iv) non-disclosure agreements, (v) reporting requirements, and (vi) an appeals process for appeals on certain procedural grounds. The measure requires the State Corporation Commission to contract with Virginia Health Information (VHI) to establish a data set and business protocols to provide health carriers, providers, and arbitrators with data to assist in determining commercially reasonable payments and resolving disputes. The measure requires the Commission, in consultation with health carriers, providers, and consumers, to develop standard language for a notice of consumer rights regarding balance billing. The measure authorizes the Commission, the Board of Medicine, and the Commissioner of Health to levy fines and take action against a health carrier, health care practitioner, or medical care facility, respectively, for a pattern of violations of the prohibition against balance billing. Additionally, the measure prohibits a carrier or provider from initiating arbitration with such frequency as to indicate a general business practice. The measure provides that such provisions do not apply to an entity that provides or administers self-insured or self-funded plans; however, such entities may elect to be subject such provisions. The measure authorizes the Commission to adopt rules and regulations governing the arbitration process. The measure has a delayed effective date of January 1, 2021. This bill incorporates HB 58, HB 189, HB 901, HB 1494, and HB 1546 and is identical to SB 172. 

SUMMARY AS PASSED HOUSE:

Health insurance; payment to out-of-network providers. Provides that when a covered person receives covered emergency services from an out-of-network health care provider or receives out-of-network services at an in-network facility, the covered person is not required to pay the out-of-network provider any amount other than the applicable cost-sharing requirement. The measure also establishes a standard for calculating the health carrier's required payment to the out-of-network provider of the 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 provides that such provisions do not apply to an entity that provides or administers self-insured or self-funded plans; however, such entities may elect to be subject to such provisions. The measure requires health carriers to make reports to the Bureau of Insurance and directs the Bureau to provide reports to certain committees of the General Assembly. The measure requires the nonprofit data services organization contracting with the Department of Health to operate the All Payer Claims Database to convene an advisory work group to make recommendations for a methodology to be used for identifying codes for comparable emergency services and statistical adjustments to account for outlier payment amounts for each health planning region to be used for the market-based value calculation and submit its recommendations to the Commissioner of Insurance no later than December 31, 2020. This bill incorporates HB 58, HB 189, HB 901, HB 1494, and HB 1546.

SUMMARY AS INTRODUCED:

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.