Bill Text: VA HB1731 | 2020 | Regular Session | Introduced
Bill Title: Health care provider panel; definition of "vertically-integrated carrier."
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2020-02-04 - Continued to 2021 in Labor and Commerce by voice vote [HB1731 Detail]
Download: Virginia-2020-HB1731-Introduced.html
Be it enacted by the General Assembly of Virginia:
1. That §§ 38.2-3407.10 and 38.2-4319 of the Code of Virginia are amended and reenacted as follows:
§38.2-3407.10. Health care provider panels.
A. As used in this section:
"Carrier" means:
1. Any insurer proposing to issue individual or group accident and sickness insurance policies providing hospital, medical and surgical or major medical coverage on an expense incurred basis;
2. Any corporation providing individual or group accident and sickness subscription contracts;
3. Any health maintenance organization providing health care plans for health care services;
4. Any corporation offering prepaid dental or optometric services plans; or
5. Any other person or organization that provides health benefit plans subject to state regulation, and includes an entity that arranges a provider panel for compensation.
"Enrollee" means any person entitled to health care services from a carrier.
"Provider" means a hospital, physician or any type of provider licensed, certified or authorized by statute to provide a covered service under the health benefit plan.
"Provider panel" means those providers with which a carrier contracts to provide health care services to the carrier's enrollees under the carrier's health benefit plan. However, such term does not include an arrangement between a carrier and providers in which any provider may participate solely on the basis of the provider's contracting with the carrier to provide services at a discounted fee-for-service rate.
"Vertically-integrated carrier" means a carrier that owns or controls, is owned or controlled by, or is under common ownership or control with, an individual, partnership, committee, association, corporation, or any other organization or group of persons that, either directly or through one or more affiliates or subsidiaries, owns, operates, or manages one or more acute care hospital facilities operating in the Commonwealth.
B. Any such carrier that offers a provider panel shall establish and use it in accordance with the following requirements:
1. Notice of the development of a provider panel in the Commonwealth or local service area shall be filed with the Department of Health Professions.
2. Carriers shall provide a provider application and the relevant terms and conditions to a provider upon request.
C. A carrier that uses a provider panel shall establish procedures for:
1. Notifying an enrollee of:
a. The termination from the carrier's provider panel of the enrollee's primary care provider who was furnishing health care services to the enrollee; and
b. The right of an enrollee upon request to continue to receive health care services for a period of up to 90 days from the date of the primary care provider's notice of termination from a carrier's provider panel, except when a provider is terminated for cause.
2. Notifying a provider at least 90 days prior to the date of the termination of the provider, except when a provider is terminated for cause.
3. Providing reasonable notice to primary care providers in the carrier's provider panel of the termination of a specialty referral services provider.
4. Notifying the purchaser of the health benefit plan, whether such purchaser is an individual or an employer providing a health benefit plan, in whole or in part, to its employees and enrollees of the health benefit plan of:
a. A description of all types of payment arrangements that the carrier uses to compensate providers for health care services rendered to enrollees, including, but not limited to, withholds, bonus payments, capitation and fee-for-service discounts; and
b. The terms of the plan in clear and understandable language that reasonably informs the purchaser of the practical application of such terms in the operation of the plan.
D. Whenever a provider voluntarily terminates his contract with a carrier to provide health care services to the carrier's enrollees under a health benefit plan, he shall furnish reasonable notice of such termination to his patients who are enrollees under such plan.
E. A carrier may not deny an application for participation or terminate participation on its provider panel on the basis of gender, race, age, religion or national origin.
F. 1. For a period of at least 90 days from the date of the notice of a provider's termination from the carrier's provider panel, except when a provider is terminated for cause, the provider shall be permitted by the carrier to render health care services to any of the carrier's enrollees who:
a. Were in an active course of treatment from the provider prior to the notice of termination; and
b. Request to continue receiving health care services from the provider.
2. Notwithstanding the provisions of subdivision 1, any provider shall be permitted by the carrier to continue rendering health services to any enrollee who has entered the second trimester of pregnancy at the time of a provider's termination of participation, except when a provider is terminated for cause. Such treatment shall, at the enrollee's option, continue through the provision of postpartum care directly related to the delivery.
3. Notwithstanding the provisions of subdivision 1, any provider shall be permitted by the carrier to continue rendering health services to any enrollee who is determined to be terminally ill (as defined under §1861 (dd)(3)(A) of the Social Security Act) at the time of a provider's termination of participation, except when a provider is terminated for cause. Such treatment shall, at the enrollee's option, continue for the remainder of the enrollee's life for care directly related to the treatment of the terminal illness.
4. A carrier shall reimburse a provider under this subsection in accordance with the carrier's agreement with such provider existing immediately before the provider's termination of participation.
G.
1. A carrier shall provide to a purchaser upon enrollment and make available to existing enrollees at least once a year a list of members in its provider panel, which list shall also indicate those providers who are not currently accepting new patients. Such list may be made available in a form other than a printed document, provided the purchaser or existing enrollee is given the means to request and receive a printed copy of such list.
2. The information provided under subdivision 1 shall be updated at least once a year if in paper form, and monthly if in electronic form.
H. No contract between a carrier and a provider may require that the provider indemnify the carrier for the carrier's negligence, willful misconduct, or breach of contract, if any.
I. No contract between a carrier and a provider shall require a provider, as a condition of participation on the panel, to waive any right to seek legal redress against the carrier.
J. No contract between a carrier and a provider shall prohibit, impede or interfere in the discussion of medical treatment options between a patient and a provider.
K. A contract between a carrier and a provider shall permit and require the provider to discuss medical treatment options with the patient.
L. Any carrier requiring preauthorization for medical treatment shall have personnel available to provide such preauthorization at all times when such preauthorization is required.
M. Carriers shall provide to their group policyholders written notice of any benefit reductions during the contract period at least 60 days before such benefit reductions become effective. Group policyholders shall, in turn, provide to their enrollees written notice of any benefit reductions during the contract period at least 30 days before such benefit reductions become effective. Such notice shall be provided to the group policyholder as a separate and distinct notification, and may not be combined with any other notification or marketing materials.
N. No contract between a provider and a carrier shall include provisions that require a health care provider or health care provider group to deny covered services that such provider or group knows to be medically necessary and appropriate that are provided with respect to a specific enrollee or group of enrollees with similar medical conditions.
O. If a provider panel contract between a provider and a
carrier, or other entity that provides hospital, physician or other health care
services to a carrier, includes provisions that require a provider, as a
condition of participating in one of the carrier's or other entity's provider
panels, to participate in any other provider panel owned or operated by that
carrier or other entity, the contract shall contain a provision permitting the
provider to refuse participation in one or more such other provider panels at
the time the contract is executed. If a provider contracts with a carrier or
other entity that subsequently contracts with one or more unaffiliated carriers
to include such provider in the provider panels of such unaffiliated carriers,
and which permits an unaffiliated carrier to impose participation terms with
respect to such provider that differ materially in reimbursement rates or in
managed care procedures, such as conducting economic profiling or requiring a
patient to obtain primary care physician referral to a specialist, from the
terms agreed to by the provider in the original contract, the provider panel
contract shall contain a provision permitting the provider to refuse
participation with any such unaffiliated carrier. Utilization review pursuant
to Article 1.2 (§Section 32.1-137.7
et seq.) of Chapter 5 of Title 32.1 shall not constitute a materially different
managed care procedure. This subsection shall apply to provider panels utilized
by health maintenance organizations and preferred provider organizations. For
purposes of this subsection, "preferred provider organization" means
a carrier that offers preferred provider contracts or policies as defined in §
Section 38.2-3407 or preferred
provider subscription contracts as defined in §Section
38.2-4209. The status of a physician as a member of or as being
eligible for other existing or new provider panels shall not be adversely
affected by the exercise of such right to refuse participation. This subsection
shall not apply to the Medallion II and children's health insurance plan
administered by or pursuant to contract with the Department of Medical
Assistance Services.
P. A carrier that rents or leases its provider panel to unaffiliated carriers shall make available, upon request, to its providers a list of unaffiliated carriers that rent or lease its provider panel. Such list if available in electronic format shall be updated monthly. The provider shall be given the means to request and receive a printed copy of such list.
Q. The Commission shall have no jurisdiction to
adjudicate controversies arising out of this section.
Q. Each vertically-integrated carrier shall offer participation in each provider panel or network established for each of the vertically-integrated carrier's policies, products, and plans, including all policies, products, and plans offered to individuals, employers, and enrollees in government benefit programs, including the Medical Assistance and Children's Health Insurance Programs, to every Provider in the Commonwealth on the same terms and conditions (including, without limitation, quality requirements) that it applies to Providers under common control with the vertically-integrated carrier. Such participation shall:
1. Be without any adverse tiering or other financial incentives that may discourage enrollees from utilizing the services of the Provider, unless there are objective, reasonable criteria to establish different tiers of Providers based upon price, quality, or access that are applied in a non-discriminatory manner to all Providers, regardless of affiliation with the vertically-integrated carrier. Criteria will be deemed "objective" if the criteria are capable of mathematical determination and subject to independent verification and audit by a third party without conflict of interest at the sole expense of the vertically-integrated carrier. Criteria will be deemed "reasonable" if the vertically-integrated carrier bases them upon the recommendations of CMS, a nationally recognized accreditation organization, or a physician specialty society;
2. Include all sites and services offered by the Provider, so long as such sites and services are appropriately licensed and meet the standards of the vertically-integrated carrier's generally applicable clinical credentialing criteria and the services offered are otherwise covered by the carrier; and
3. Take into account the different characteristics of different Providers with regard to the range, nature, cost, and complexity of services offered. The vertically-integrated carrier may offer different reimbursement rates to different Providers, provided that the vertically-integrated carrier shall offer Providers with which it is not under common control reimbursement rates that are no lower than the reimbursement rates offered to the highest-paid similarly-situated Provider with which the vertically-integrated carrier is under common control. For purposes of this subsection "similarly-situated Providers" are defined as follows: (1) physicians of the same specialty, except for pediatric subspecialty physicians who will only be deemed similarly-situated to other physicians practicing in the same pediatric subspecialty; (2) acute care hospitals that do not participate in graduate medical education programs will be deemed similarly-situated to other acute care hospitals that do not participate in graduate medical education programs; (3) acute care hospitals that participate in graduate medical education programs shall be deemed similarly-situated to other acute care hospitals that participate in graduate medical education programs, except that stand-alone specialty children's hospitals shall only be deemed similarly-situated to other stand-alone specialty children's hospitals; (4) providers other than physicians and acute care hospitals shall be deemed similarly-situated to other providers operating under the same licensure and providing substantially similar services. Providers can only be deemed to be similarly-situated to other Providers rendering services within the same metropolitan statistical area as delineated by the U.S. Office of Management and Budget ("MSA"). If there is an acute care hospital that participates in graduate medical education programs in a particular MSA that is not under common control with the vertically-integrated carrier but there is no similarly-situated Provider within the same MSA with which the vertically-integrated carrier is under common control, then the vertically-integrated carrier shall offer such acute care hospital reimbursement rates that are no less than the greater of either (i) the highest reimbursement rates paid by the vertically-integrated carrier to any acute care hospital in the relevant MSA or (ii) the highest reimbursement rates paid by the vertically-integrated to an acute care hospital in this Commonwealth that participates in graduate medical education programs, regardless of which MSA such acute care hospital is located within.
4. So long as the vertically-integrated carrier has complied with subdivisions Q 1, Q 2, and Q 3, it may exclude or limit the participation of any provider on any ground otherwise permitted by § 38.2-3407(B), §38.2-4209(C), or §38.2-4312(E).
R. No officer or director of a vertically-integrated carrier may simultaneously serve as an officer or director of an entity that owns, operates, manages, or controls, in whole or in part, directly or indirectly through one or more parents, subsidiaries, affiliates, or other entities sharing the same ultimate ownership or control, an acute care hospital located, in whole or in part, in the Commonwealth of Virginia.
S. The Commission shall have jurisdiction to adjudicate controversies arising out of subsections Q and R of this section. The Commission shall have no jurisdiction to adjudicate controversies arising out of any other subsections of this section.
R. T. The
requirements of this section shall apply to all insurance policies, contracts,
and plans delivered, issued for delivery, reissued, or extended on or after
July 1, 1996. However, the 90-day period referred to in subdivisions C 1 b and
C 2 of this section, the requirements set forth in subdivisions F 2 and F 3,
and the requirements set forth in subsections L, M, and N shall apply to
contracts between carriers and providers that are entered into or renewed on or
after July 1, 1999, the requirements set forth in subsection O shall apply to
contracts between carriers and providers that are entered into, reissued,
extended or renewed on or after July 1, 2001, and the requirements set forth in
subsection P shall be effective on and after January 1, 2007.;
and the requirements set forth in subsection Q shall apply to contracts between
carriers and providers that are in effect on or after July 1, 2020. The
requirements set forth in subsection R shall be effective as of July 1, 2020.
§38.2-4319. Statutory construction and relationship to other laws.
A. No provisions of this title except this chapter and,
insofar as they are not inconsistent with this chapter, §§Sections
38.2-100, 38.2-136, 38.2-200, 38.2-203, 38.2-209 through 38.2-213,
38.2-216, 38.2-218 through 38.2-225, 38.2-229, 38.2-232, 38.2-305, 38.2-316,
38.2-316.1, 38.2-322, 38.2-325, 38.2-326, 38.2-400, 38.2-402 through 38.2-413,
38.2-500 through 38.2-515, 38.2-600 through 38.2-620, Chapter 9 (§
Section 38.2-900 et seq.), §§
Sections 38.2-1016.1 through
38.2-1023, 38.2-1057, 38.2-1306.1, Article 2 (§Section38.2-1306.2
et seq.), §Section 38.2-1315.1,
Articles 3.1 (§Section 38.2-1316.1
et seq.), 4 (§Section 38.2-1317
et seq.), 5 (§Section 38.2-1322
et seq.), 5.1 (§Section 38.2-1334.3
et seq.), and 5.2 (§Section 38.2-1334.11
et seq.) of Chapter 13, Articles 1 (§Section
38.2-1400 et seq.), 2 (§Section
38.2-1412 et seq.), and 4 (§Section
38.2-1446 et seq. ) of Chapter 14, Chapter 15 (§Section
38.2-1500 et seq.), Chapter 17 (§Section
38.2-1700 et seq.), §§Sections
38.2-1800 through 38.2-1836, 38.2-3401, 38.2-3405, 38.2-3405.1,
38.2-3406.1, 38.2-3407.2 through 38.2-3407.6:1, 38.2-3407.9 through
38.2-3407.20, 38.2-3411, 38.2-3411.2, 38.2-3411.3, 38.2-3411.4, 38.2-3412.1,
38.2-3414.1, 38.2-3418.1 through 38.2-3418.17, 38.2-3419.1, 38.2-3430.1 through
38.2-3454, Article 8 (§Section 38.2-3461
et seq.) of Chapter 34, 38.2-3500, subdivision 13 of §Section
38.2-3503, subdivision 8 of §Section
38.2-3504, §§Section 38.2-3514.1,
38.2-3514.2, 38.2-3522.1 through 38.2-3523.4, 38.2-3525, 38.2-3540.1,
38.2-3540.2, 38.2-3541.2, 38.2-3542, 38.2-3543.2, Article 5 (§
Section 38.2-3551 et seq.) of Chapter
35, Chapter 35.1 (§Section 38.2-3556
et seq.), Chapter 52 (§Section 38.2-5200
et seq.), Chapter 55 (§Section 38.2-5500
et seq.), and Chapter 58 (§Section 38.2-5800
et seq.) shall be applicable to any health maintenance organization granted a
license under this chapter. This chapter shall not apply to an insurer or
health services plan licensed and regulated in conformance with the insurance
laws or Chapter 42 (§Section 38.2-4200
et seq.) except with respect to the activities of its health maintenance
organization.
B. For plans administered by the Department of Medical
Assistance Services that provide benefits pursuant to Title XIX or Title XXI of
the Social Security Act, as amended, no provisions of this title except this
chapter and, insofar as they are not inconsistent with this chapter, §§
Sections 38.2-100, 38.2-136, 38.2-200,
38.2-203, 38.2-209 through 38.2-213, 38.2-216, 38.2-218 through 38.2-225,
38.2-229, 38.2-232, 38.2-322, 38.2-325, 38.2-400, 38.2-402 through 38.2-413,
38.2-500 through 38.2-515, 38.2-600 through 38.2-620, Chapter 9 (§
Section 38.2-900 et seq.), §§
Sections 38.2-1016.1 through
38.2-1023, 38.2-1057, 38.2-1306.1, Article 2 (§Section
38.2-1306.2 et seq.), §Section
38.2-1315.1, Articles 3.1 (§Section
38.2-1316.1 et seq.), 4 (§Section
38.2-1317 et seq.), 5 (§Section
38.2-1322 et seq.), 5.1 (§Section
38.2-1334.3 et seq.), and 5.2 (§Section
38.2-1334.11 et seq.) of Chapter 13, Articles 1 (§
Section 38.2-1400 et seq.), 2 (§
Section 38.2-1412 et seq.), and 4 (§
Section 38.2-1446 et seq.) of Chapter
14, §§Sections 38.2-3401,
38.2-3405, 38.2-3407.2 through 38.2-3407.5, 38.2-3407.6, 38.2-3407.6:1,
38.2-3407.9, 38.2-3407.9:01, and 38.2-3407.9:02, subdivisions F 1, F 2, and F 3,
and R and S of §Section
38.2-3407.10, §§Sections 38.2-3407.11,
38.2-3407.11:3, 38.2-3407.13, 38.2-3407.13:1, 38.2-3407.14, 38.2-3411.2,
38.2-3418.1, 38.2-3418.2, 38.2-3419.1, 38.2-3430.1 through 38.2-3437,
38.2-3500, subdivision 13 of §Section
38.2-3503, subdivision 8 of §Section
38.2-3504, §§Sections 38.2-3514.1,
38.2-3514.2, 38.2-3522.1 through 38.2-3523.4, 38.2-3525, 38.2-3540.1,
38.2-3540.2, 38.2-3541.2, 38.2-3542, 38.2-3543.2, Chapter 52 (§
Section 38.2-5200 et seq.), Chapter 55
(§Section 38.2-5500
et seq.), and Chapter 58 (§Section 38.2-5800
et seq.), shall be applicable to any health
maintenance organization granted a license under this chapter. This chapter
shall not apply to an insurer or health services plan licensed and regulated in
conformance with the insurance laws or Chapter 42 (§Section38.2-4200
et seq.) except with respect to the activities of its health maintenance
organization.
C. Solicitation of enrollees by a licensed health maintenance organization or by its representatives shall not be construed to violate any provisions of law relating to solicitation or advertising by health professionals.
D. A licensed health maintenance organization shall not be deemed to be engaged in the unlawful practice of medicine. All health care providers associated with a health maintenance organization shall be subject to all provisions of law.
E. Notwithstanding the definition of an eligible employee as
set forth in §Section 38.2-3431,
a health maintenance organization providing health care plans pursuant to §
Section 38.2-3431 shall not be
required to offer coverage to or accept applications from an employee who does
not reside within the health maintenance organization's service area.
F. For purposes of applying this section, "insurer" when used in a section cited in subsections A and B shall be construed to mean and include "health maintenance organizations" unless the section cited clearly applies to health maintenance organizations without such construction.
