                                 CODE OF VIRGINIA

OUT-OF-NETWORK CLAIMS; REPORTING REQUIREMENTS (§ 38.2-3445.2)

A. Any health carrier providing individual or group health insurance coverage
shall report to the State Corporation Commission&#8217;s Bureau of Insurance
(the Bureau) no later than September 1, 2020, the number of out-of-network
claims for emergency services paid pursuant to subdivision A 4 of &#xA7;
38.2-3445 in fiscal years 2017, 2018, and 2019. Thereafter, any health carrier
providing individual or group health insurance coverage shall report to the
Bureau, no later than November 1 of each year, the number of out-of-network
claims for services described in subsection A of &#xA7; 38.2-3445.01 for the
previous fiscal year.

B. Any health carrier providing individual or group health insurance coverage
shall report to the Bureau no later than September 1 of each year the number and
identity of health care providers in the health carrier&#8217;s network of
emergency services providers and surgical or ancillary providers whose
participation in the network was terminated by either the health carrier or the
health care provider in the previous year and, if applicable, whether
participation was subsequently reinstated in the same year. For any terminated
health care providers identified by the health carrier in such report, the
health carrier shall include (i) a description of the health care
provider&#8217;s or health carrier&#8217;s stated reason for terminating
participation and (ii) a description of the nature and extent of differences in
payment levels for emergency services and surgical or ancillary services prior
to termination and after reinstatement, if applicable, including a determination
of whether such payment levels after reinstatement were higher or lower than
those applied prior to termination.

C. The Bureau shall notify the Chairmen of the House Committee on Labor and
Commerce and the Senate Committee on Commerce and Labor of the information
reported to the Bureau pursuant to subsections A and B and other information
specified in this subsection no later than December 1, 2021, and annually
thereafter. Such notice shall include (i) the number of out-of-network claims
for services described in subsection A of &#xA7; 38.2-3445.01 for the previous
fiscal year; (ii) the number and identity of health care providers in the health
carrier&#8217;s network of emergency services providers and surgical or
ancillary services providers whose participation in the network was terminated
by the health carrier or the health care provider in the previous year and
whether participation was subsequently reinstated in the same year; (iii) a
summary of the stated reasons for terminating participation; (iv) a summary of
the nature and extent of differences in payment levels prior to termination and
after reinstatement, if applicable, including a determination of whether such
payment levels after reinstatement were higher or lower than those applied prior
to termination; (v) an assessment by the Bureau of the potential impact of any
changes in network participation or payment levels for emergency services on
health insurance premiums in the time period to which the report applies; and
(vi) the number and type of claims resolved by arbitration and aggregate
information on the disposition of those arbitrations, including in which
category group&#8217;s favor the dispute was resolved, and aggregate information
on the variation between the initial payment and final settlement amounts.

HISTORY: 2020, cc. 1080, 1081.