Health insurance; definitions, payment to out-of-network providers, emergency services. (SB172)

Introduced By

Sen. Barbara Favola (D-Arlington) with support from co-patrons Sen. Jennifer Boysko (D-Herndon), Sen. Siobhan Dunnavant (R-Henrico), Sen. John Edwards (D-Roanoke), and Sen. Jennifer McClellan (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 which 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 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 to 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 SB 522 and is identical to HB 1251. Read the Bill »


Bill Has Passed


12/20/2019Prefiled and ordered printed; offered 01/08/20 20101733D
12/20/2019Referred to Committee on Commerce and Labor
01/15/2020Assigned C&L sub: Health Insurance
01/16/2020Impact statement from DPB (SB172)
01/31/2020Impact statement from DPB (SB172)
02/09/2020Reported from Commerce and Labor with substitute (8-Y 7-N) (see vote tally)
02/09/2020Committee substitute printed 20107408D-S1
02/09/2020Rereferred to Finance and Appropriations
02/10/2020Reported from Finance and Appropriations with amendments (11-Y 5-N) (see vote tally)
02/11/2020Read second time
02/11/2020Reading of substitute waived
02/11/2020Committee substitute agreed to 20107408D-S1
02/11/2020Reading of amendments waived
02/11/2020Committee amendments agreed to
02/11/2020Engrossed by Senate - committee substitute with amendments SB172ES1
02/11/2020Printed as engrossed 20107408D-ES1
02/11/2020Constitutional reading dispensed (40-Y 0-N) (see vote tally)
02/11/2020Passed Senate (36-Y 4-N) (see vote tally)
02/14/2020Placed on Calendar
02/14/2020Read first time
02/14/2020Referred to Committee on Labor and Commerce
02/18/2020Referred from Labor and Commerce
02/18/2020Referred to Committee on Appropriations
02/20/2020Impact statement from DPB (SB172ES1)
02/23/2020Assigned App. sub: Health & Human Resources
02/25/2020Impact statement from DPB (SB172ES1)
02/26/2020House subcommittee amendments and substitutes offered
02/26/2020Subcommittee recommends reporting with substitute (8-Y 0-N)
02/28/2020House committee, floor amendments and substitutes offered
02/28/2020Committee substitute printed 20109092D-H1
02/28/2020Reported from Appropriations with substitute (22-Y 0-N) (see vote tally)
02/28/2020Incorporates SB522
03/02/2020Impact statement from DPB (SB172H1)
03/03/2020Read second time
03/04/2020Floor substitute printed 20109578D-H2 (Torian)
03/04/2020Passed by for the day
03/05/2020Read third time
03/05/2020Committee substitute rejected 20109092D-H1
03/05/2020Substitute by Delegate Torian agreed to 20109578D-H2
03/05/2020Engrossed by House - floor substitute SB172H2
03/05/2020Passed House with substitute (99-Y 0-N)
03/05/2020VOTE: Passage (99-Y 0-N) (see vote tally)
03/05/2020House substitute agreed to by Senate (39-Y 0-N) (see vote tally)
03/05/2020Title replaced 20109578D-H2
03/12/2020Bill text as passed Senate and House (SB172ER)
03/12/2020Signed by President
03/12/2020Signed by Speaker
03/16/2020Impact statement from DPB (SB172H2)
03/16/2020Impact statement from DPB (SB172ER)
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 1081 (effective 7/1/20)
04/10/2020G Acts of Assembly Chapter text (CHAP1081)
04/10/2020G Approved by Governor-Chapter 1081 (effective - see bill)

Duplicate Bills

The following bills are identical to this one: HB1251 and HB1494.