                                 CODE OF VIRGINIA

BALANCE BILLING FOR CERTAIN SERVICES; PROHIBITED (§ 38.2-3445.01)

A. No out-of-network provider shall balance bill an enrollee for (i) emergency
services provided to an enrollee or (ii) nonemergency services provided to an
enrollee at an in-network facility if the nonemergency services involve surgical
or ancillary services provided by an out-of-network provider.

B. An enrollee that receives services described in subsection A satisfies his
obligation to pay for the services if he pays the in-network cost-sharing
requirement specified in the enrollee&#8217;s or applicable group health plan
contract. The enrollee&#8217;s obligation shall be determined using the
carrier&#8217;s median in-network contracted rate for the same or similar
service in the same or similar geographical area. The carrier shall provide an
explanation of benefits to the enrollee and the out-of-network provider that
reflects the cost-sharing requirement determined under this subsection. The
obligation of an enrollee in a health benefit plan that uses no median
in-network contracted rate for the services provided shall be determined as
provided in &#xA7; 38.2-3407.3.

C. The health carrier and the out-of-network provider shall ensure that the
enrollee incurs no greater cost than the amount determined under subsection B
and shall not balance bill or otherwise attempt to collect from the enrollee any
amount greater than such amount. Additional amounts owed to health care
providers through good faith negotiations or arbitration shall be the sole
responsibility of the carrier unless the carrier is prohibited from providing
the additional benefits under 26 U.S.C. &#xA7; 223(c)(2) or any other federal or
state law. Nothing in this subsection shall preclude a provider from collecting
a past due balance on a cost-sharing requirement with interest.

D. The health carrier shall treat any cost-sharing requirement determined under
subsection B in the same manner as the cost-sharing requirement for health care
services provided by an in-network provider and shall apply any cost-sharing
amount paid by the enrollee for such services toward the in-network maximum
out-of-pocket payment obligation.

E. If the enrollee pays the out-of-network provider an amount that exceeds the
amount determined under subsection B, the provider shall refund the excess
amount to the enrollee within 30 business days of receipt. The provider shall
pay the enrollee interest computed daily at the legal rate of interest stated in
&#xA7; 6.2-301 beginning on the first calendar day after the 30 business days
for any unrefunded payments.

F. The amount paid to an out-of-network provider for health care services
described in subsection A shall be a commercially reasonable amount, based on
payments for the same or similar services provided in a similar geographic area.
Within 30 calendar days of receipt of a clean claim from an out-of-network
provider, the carrier shall offer to pay the provider a commercially reasonable
amount. If the out-of-network provider disputes the carrier&#8217;s payment, the
provider shall notify the carrier no later than 30 calendar days after receipt
of payment or payment notification from the carrier. If the out-of-network
provider disputes the carrier&#8217;s initial offer, the carrier and provider
shall have 30 calendar days from the initial offer to negotiate in good faith.
If the carrier and provider do not agree to a commercially reasonable payment
amount within 30 calendar days and either party chooses to pursue further action
to resolve the dispute, the dispute shall be resolved through arbitration as
provided in &#xA7; 38.2-3445.02.

G. The carrier shall make payments for services described in subsection A
directly to the provider.

H. Carriers shall make available through electronic and other methods of
communication generally used by a provider to verify enrollee eligibility and
benefits information regarding whether an enrollee&#8217;s health plan is
subject to the requirements of this section.

HISTORY: 2020, cc. 1080, 1081.