Signed by Governor Ralph Northam

Vote Smart's Synopsis:

A vote to pass a substitute bill that authorizes enrollee not to pay out-of-network amount except applicable cost-sharing requirement.

Highlights:

• Prohibits an out-of-network provider to bill an enrollee for (Sec 1):

• Emergency services provided to an enrollee; or

• Non-emergency services provided to an enrollee at an in-network facility if the non-emergency services involved surgical or ancillary services provided by an out-of-network provider.

• Specifies that an enrollee satisfies their payment obligation if they pay the in-network cost-sharing requirement in their health plan contract (Sec 1).

• Requires the health carrier and out-of-network provider to ensure that the enrollee incurs no greater cost than the median in-network contracted rate for the same or similar services in the geographic area (Sec 1).

• Specifies that the carrier shall provide an explanation of benefits to the enrollee and the out-of-network provider that reflects the cost-sharing requirement (Sec. 1).

• Specifies that the amount paid to an out-of-network provider for health care services shall be a commercially reasonable amount, based on payments for the same or similar services provided in a similar geographic area (Sec. 1).

• Specifies that the parties may reach an agreement on reimbursement during this time and before the arbitration proceeding and specifies that (Sec. 1):

• The parties shall be permitted to bundle claims for arbitration; and

• Within 7 calendar days of receipt of notification from the initiating party, the Commission shall provide the parties with a list of approved arbitrators or entities that provide arbitrations.

• Establishes that the Commission shall contract with the nonprofit data services organization to establish a data set and business process to provide health carriers, health care providers, and arbitrators with data to assist in determining commercially reasonable payments and resolving payment disputes for out-of-network medical services rendered by health care providers (Sec. 1).

• Specifies that the Commission, in consultation with health carriers, health care providers, and consumers, shall develop standard template language for a notice of consumer rights notifying consumers of the following (Sec. 1):

• The prohibition against balance billing is applicable to health benefit plans issued by health carriers in Virginia and self-funded group health plans; and

• Consumers cannot be billed for the balance of their health care services.

Full Bill Text