Health insurance; definitions, payment to out-of-network providers, emergency services. (HB1251)

Introduced By

Del. Luke Torian (D-Woodbridge) with support from co-patron Del. Lamont Bagby (D-Richmond)


Passed Committee
Passed House
Passed Senate
Signed by Governor
Became Law


Health insurance; payment to out-of-network providers. Provides that when an enrollee receives emergency services from an out-of-network health care provider or receives out-of-network surgical or ancillary services at an in-network facility, the enrollee is not required to pay the out-of-network provider any amount other than the applicable cost-sharing requirement and such cost-sharing requirement cannot exceed the cost-sharing requirement that would apply if the services were provided in-network. The measure also provides that the health carrier's required payment to the out-of-network provider of the services is a commercially reasonable amount based on payments for the same or similar services provided in a similar geographic area. If such provider disputes the amount to be paid by the health carrier, the measure requires the provider and the health carrier to make a good faith effort to reach a resolution on the amount of the reimbursement. If the health carrier and the provider do not agree to a commercially reasonable payment and either party wants to take further action to resolve the dispute, then the measure requires the dispute will be resolved by arbitration. The measure establishes a framework for arbitration of such disputes that includes (i) a timeline for the proceedings, (ii) a method for choosing an arbitrator, (iii) required and optional factors for the arbitrator to consider, (iv) non-disclosure agreements, (v) reporting requirements, and (vi) an appeals process for appeals on certain procedural grounds. The measure requires the State Corporation Commission to contract with Virginia Health Information (VHI) to establish a data set and business protocols to provide health carriers, providers, and arbitrators with data to assist in determining commercially reasonable payments and resolving disputes. The measure requires the Commission, in consultation with health carriers, providers, and consumers, to develop standard language for a notice of consumer rights regarding balance billing. The measure authorizes the Commission, the Board of Medicine, and the Commissioner of Health to levy fines and take action against a health carrier, health care practitioner, or medical care facility, respectively, for a pattern of violations of the prohibition against balance billing. Additionally, the measure prohibits a carrier or provider from initiating arbitration with such frequency as to indicate a general business practice. The measure provides that such provisions do not apply to an entity that provides or administers self-insured or self-funded plans; however, such entities may elect to be subject such provisions. The measure authorizes the Commission to adopt rules and regulations governing the arbitration process. The measure has a delayed effective date of January 1, 2021. This bill incorporates HB 58, HB 189, HB 901, HB 1494, and HB 1546 and is identical to SB 172. Read the Bill »


Bill Has Passed


01/08/2020Prefiled and ordered printed; offered 01/08/20 20102088D
01/08/2020Referred to Committee on General Laws
01/16/2020Impact statement from DPB (HB1251)
01/16/2020Referred from General Laws
01/16/2020Referred to Committee on Labor and Commerce
01/23/2020Assigned L & C sub: Subcommittee #2
01/30/2020Subcommittee recommends reporting with substitute (8-Y 0-N)
01/30/2020Subcommittee recommends referring to Committee on Appropriations
02/04/2020Reported from Labor and Commerce with substitute (22-Y 0-N) (see vote tally)
02/04/2020Referred to Committee on Appropriations
02/04/2020Committee substitute printed 20107376D-H1
02/04/2020Incorporates HB1546 (Adams)
02/04/2020Incorporates HB1494 (Bagby)
02/04/2020Incorporates HB58 (Ware)
02/06/2020Impact statement from DPB (HB1251H1)
02/07/2020Committee substitute printed 20108018D-H2
02/07/2020Incorporates HB1546 (Adams)
02/07/2020Incorporates HB1494 (Bagby)
02/07/2020Incorporates HB189 (Levine)
02/07/2020Incorporates HB901 (Sickles)
02/07/2020Incorporates HB58 (Ware)
02/07/2020Reported from Appropriations with substitute (22-Y 0-N) (see vote tally)
02/09/2020Read first time
02/10/2020House committee, floor amendments and substitutes offered
02/10/2020Read second time
02/10/2020Committee Labor and Commerce substitute rejected 20107376D-H1
02/10/2020Committee on Appropriations substitute agreed to 20108018D-H2
02/10/2020Amendments by Delegate Torian agreed to
02/10/2020Engrossed by House - committee substitute with amendments HB1251EH1
02/10/2020Printed as engrossed 20108018D-EH1
02/11/2020Read third time and passed House (94-Y 5-N)
02/11/2020VOTE: Passage (94-Y 5-N) (see vote tally)
02/12/2020Constitutional reading dispensed
02/12/2020Referred to Committee on Commerce and Labor
02/20/2020Impact statement from DPB (HB1251EH1)
02/24/2020Reported from Commerce and Labor with substitute (13-Y 2-N) (see vote tally)
02/24/2020Committee substitute printed 20109073D-S1
02/24/2020Rereferred to Finance and Appropriations
02/25/2020Impact statement from DPB (HB1251S1)
03/02/2020Reported from Finance and Appropriations (14-Y 0-N) (see vote tally)
03/04/2020Constitutional reading dispensed (40-Y 0-N) (see vote tally)
03/05/2020Floor substitute printed 20109579D-S2 (Favola)
03/05/2020Read third time
03/05/2020Committee substitute rejected 20109073D-S1
03/05/2020Reading of substitute waived
03/05/2020Substitute by Senator Favola agreed to 20109579D-S2
03/05/2020Engrossed by Senate - committee substitute HB1251S2
03/05/2020Passed Senate with substitute (40-Y 0-N) (see vote tally)
03/05/2020Senate substitute agreed to by House 20109073D-S1 (98-Y 0-N)
03/05/2020VOTE: Adoption (98-Y 0-N) (see vote tally)
03/12/2020Bill text as passed House and Senate (HB1251ER)
03/12/2020Signed by Speaker
03/12/2020Signed by President
03/16/2020Impact statement from DPB (HB1251S2)
03/16/2020Impact statement from DPB (HB1251ER)
03/17/2020Enrolled Bill communicated to Governor on March 17, 2020
03/17/2020G Governor's Action Deadline 11:59 p.m., April 11, 2020
04/10/2020G Approved by Governor-Chapter 1080 (effective 7/1/20)
04/10/2020G Acts of Assembly Chapter text (CHAP1080)
04/10/2020G Approved by Governor-Chapter 1080 (effective - see bill)

Duplicate Bills

The following bills are identical to this one: SB172 and HB1494.