                                 CODE OF VIRGINIA

HEALTH CARE PROVIDER PANELS (§ 38.2-3407.10)

A. As used in this section:
			&#8220;Carrier&#8221; 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.
   				&#8220;Enrollee&#8221; means any person entitled to health care services
   from a carrier.
   				&#8220;Provider&#8221; 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.
   				&#8220;Provider panel&#8221; means those providers with which a carrier
   contracts to provide health care services to the carrier&#8217;s enrollees
   under the carrier&#8217;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&#8217;s contracting with
   the carrier to provide services at a discounted fee-for-service rate.

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&#8217;s provider panel of a provider
   who was furnishing health care services to the enrollee or furnished health
   care services to the enrollee in the 12 months prior to the notice; and
   				b. The right of an enrollee to continue to receive health care services as
   provided in subsection E following the provider&#8217;s termination from a
   carrier&#8217;s provider panel, except when a provider is terminated for
   cause.
   				The carrier shall provide notice required by this subdivision 1 prior to
   the date of the termination of the provider, 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. 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 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.
   				For the purposes of subdivisions 1 and 2, &#8220;provider&#8221; includes
   a provider group.

D. A carrier shall not deny an application for participation or terminate
participation on its provider panel on the basis of gender, race, age, sexual
orientation, gender identity, religion, or national origin.

E. 1. A provider shall be permitted by the carrier to render health care
services to any of the carrier&#8217;s enrollees for a period of at least 90
days from the date of such provider&#8217;s termination from the carrier&#8217;s
provider panel, except when a provider is terminated for cause. A provider shall
continue to render health care services to any of the carrier&#8217;s enrollees
who have an existing provider-patient relationship with the provider for a
period of at least 90 days from the date of such provider&#8217;s termination
from the carrier&#8217;s provider panel, except when a provider is terminated
for cause.

   2. Notwithstanding the provisions of subdivision 1, any provider shall be
   permitted by the carrier to continue rendering and shall continue rendering
   health services to any enrollee who has an existing provider-patient
   relationship with the provider and who has been medically confirmed to be
   pregnant at the time of a provider&#8217;s termination of participation,
   except when a provider is terminated for cause. Such treatment shall, at the
   enrollee&#8217;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 and shall continue rendering
   health services to any enrollee who has an existing provider-patient
   relationship with the provider and who is determined to be terminally ill (as
   defined under &#xA7; 1861(dd)(3)(A) of the Social Security Act) at the time of
   a provider&#8217;s termination of participation, except when a provider is
   terminated for cause. Such treatment shall, at the enrollee&#8217;s option,
   continue for the remainder of the enrollee&#8217;s life for care directly
   related to the treatment of the terminal illness.

   4. Notwithstanding the provisions of subdivision 1, any provider shall be
   permitted by the carrier to continue rendering and shall continue rendering
   health services to any enrollee who has an existing provider-patient
   relationship with the provider and who has been determined by a medical
   professional to have a life-threatening condition at the time of a
   provider&#8217;s termination of participation. Such treatment shall, at the
   enrollee&#8217;s option, continue for up to 180 days for care directly related
   to the life-threatening condition.

   5. Notwithstanding the provisions of subdivision 1, any provider shall be
   permitted by the carrier to continue rendering and shall continue rendering
   health services to any enrollee who has an existing provider-patient
   relationship with the provider and who is admitted to and receiving treatment
   in any inpatient facility at the time of a provider&#8217;s termination of
   participation. Such admission and treatment shall continue until the enrollee
   is discharged from the inpatient facility.
   				For any health care services received by an enrollee from a provider after
   the date the provider has been terminated from the carrier&#8217;s provider
   panel:
   				a. A carrier shall reimburse a provider under this subsection in
   accordance with the carrier&#8217;s agreement with such provider existing
   immediately before the provider&#8217;s termination of participation;
   				b. The provider shall accept such reimbursement from the carrier and any
   cost-sharing payment from the enrollee for items and services as payment in
   full; and
   				c. The provider shall continue to adhere to all policies and procedures
   and quality standards imposed by the carrier for an enrollee that were
   required of the provider immediately before the provider&#8217;s termination
   of participation.
   				For the purposes of this subsection, &#8220;provider&#8221; includes a
   provider group and &#8220;existing provider-patient relationship&#8221; means
   the provider has rendered health care services to the enrollee or admitted or
   discharged the enrollee in the previous 12 months.

F. 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.

G. No contract between a carrier and a provider may require that the provider
indemnify the carrier for the carrier&#8217;s negligence, willful misconduct, or
breach of contract, if any.

H. 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.

I. 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.

J. A contract between a carrier and a provider shall permit and require the
provider to discuss medical treatment options with the patient.

K. Any carrier requiring preauthorization for medical treatment shall have
personnel available to provide such preauthorization at all times when such
preauthorization is required.

L. 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 shall not be combined with any other notification or marketing
materials.

M. 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.

N. 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&#8217;s or other entity&#8217;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 (&#xA7; 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,
&#8220;preferred provider organization&#8221; means a carrier that offers
preferred provider contracts or policies as defined in &#xA7; 38.2-3407 or
preferred provider subscription contracts as defined in &#xA7; 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&#8217;s health insurance plan administered by or pursuant to a
contract with the Department of Medical Assistance Services.

O. 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.

P. Nothing in this section shall prohibit a provider from discontinuing services
to an enrollee at any time due to misconduct, a refusal to follow the
provider&#8217;s policies and procedures, or on any other reasonable basis;
however, the provider shall not discontinue services to the enrollee solely on
the basis that the provider was terminated from the carrier&#8217;s provider
panel.

Q. As part of a value-based arrangement, a provider panel contract between a
carrier and a primary care provider may include provisions that promote
comprehensive screening using evidence-based tools for mental health needs and
appropriate referrals by primary care providers to mental health services that
may be provided on-site, via telehealth on site, or through an off-site
referral.

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

HISTORY: 1996, c. 776; 1999, cc. 643, 649; 2000, cc. 862, 922, 934; 2001, c.
239; 2004, c. 715; 2006, c. 398; 2020, c. 1137; 2023, c. 490; 2024, cc. 377,
575.