Health insurance; definitions, payment to out-of-network providers, emergency services.
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SB 172 — Health insurance; definitions, payment to out-of-network providers, emergency services.
Last action — Approved by Governor-Chapter 1081 (effective - see bill)
No card. One bill, free forever — alerts when it moves.
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✓Introduced
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✓In Committee
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✓Passed Senate
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✓Passed House of Delegates
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✓To Executive
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6Enacted
This bill has been enacted into law. Introduced December 20, 2019. Enacted.
Prognosis
Where this bill stands today.
Odds of enactment
HighHow often bills like it became law.
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Enacted
Current position in the legislative process.
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10 sponsors
1 primary, 9 co-sponsors signed on.
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Mixed recorded votes
8 passed, 1 failed in recorded votes so far.
Prognosis reads this bill's own signals — stage, sponsorship breadth, committee status, recorded votes and cross-state momentum. Odds come from a model trained on which bills have become law.
Summary
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.
Bill Text
What changed in the latest version
108 added · 107 removedPlain-language change summary
The recent changes to Bill SB 172 include the addition of terms and definitions related to health care, such as "balance bill," "child," and "nonprofit data services organization." These definitions help clarify the bill's intent and improve understanding of how it pertains to health care services and coverage. Additionally, the updated language may ensure stricter confidentiality regarding recommendations for certificate suspensions or revocations. This matters because clear definitions and confidentiality protections can enhance patient rights and streamline health care administration.
Code of Virginia Administrative Code Bills & Resolutions Summaries OTHER SESSIONS - - - - - - - - - - - - - - Session Special Session I Special Session II Session Special Session I Session Special Session I Session Special Session I Special Session II Session Session Session Special Session I Session Special Session I Session Special Session I Session Special Session I Session Special Session I Session Session Special Session I Session Special Session I Special Session II Session Session Special Session I Session Session Special Session I Special Session II Session Session Session Special Session I Session Session Session Special Session I Session Session Session Session Special Session I Special Session II VIRGINIA LAW PORTALCode of VirginiaVirginia Administrative Code Constitution of VirginiaChartersAuthoritiesCompacts Uncodified ActsRIS Users (account required) SEARCHABLE DATABASESBills & Resolutionssession legislationBill Summariessession summaries Reports to the General AssemblyHouse and Senate documents Legislative LiaisonsState agency contactsACROSS SESSIONS Subject Index:
SESSION history | hilite | pdf | print version VIRGINIA ACTS OF ASSEMBLY -- CHAPTER 1081 An Act to amend and reenact §§ 32.1-137.2, 38.2-3438, 38.2-3445, and 54.1-2915 of the Code of Virginia;
[S 172] Approved April 10, 2020 Be it enacted by the General Assembly of Virginia:
The provisions of the Uniform Arbitration Act, Article 2 (§ 8.01-581.01 et seq.) of Chapter 21 of Title 8.018.01, shall not apply to arbitration proceedings initiated pursuant to this section.
Consumers cannot be balance billed for the health care services describedescribed in § 38.2-3445.01 and will receive the protections provided for in § 38.2-3445.01.
The listing of the carrier health plan provider networks with which the provider contracts with or with which the facility is an in-network provider;
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 § 38.2-3445.01 of the Code of Virginia, as created by this act, for the previous fiscal year.
(iii)(ii) the number and identity of health care providers in the health carrier'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;
(iv)(iii) a summary of the stated reasons for terminating participation;
(v)(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;
(vi)(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 (vii)(vi) the number and type of claims resolved by arbitration and aggregate information on the disposition of those arbitrations, including in which category group's favor the dispute was resolved, and aggregate information on the variation between the initial payment and final settlement amounts.
View plain text versions (6)
- Acts of Assembly Chapter text (CHAP1081) View text Current html April 10, 2020
- Bill text as passed Senate and House (SB172ER) View text html March 12, 2020
- Substitute Engrossed by House - floor substitute SB172H2 html March 04, 2020
- Impact statement from DPB (SB172H1) View text html February 28, 2020
- Committee Substitute Engrossed by Senate - committee substitute with amendments SB172ES1 html February 11, 2020
- SB172S1 View text html February 09, 2020
Action History
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Approved by Governor-Chapter 1081 (effective - see bill)
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Governor's Action Deadline 11:59 p.m., April 11, 2020
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Enrolled Bill Communicated to Governor on March 17, 2020
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Impact statement from DPB (SB172ER)
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Impact statement from DPB (SB172H2)
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Signed by Speaker
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Signed by President
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Enrolled
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Title replaced 20109578D-H2
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House substitute agreed to by Senate (39-Y 0-N)
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VOTE: Passage (99-Y 0-N)
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Passed House with substitute (99-Y 0-N)
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Engrossed by House - floor substitute SB172H2
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Substitute by Delegate Torian agreed to 20109578D-H2
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Committee substitute rejected 20109092D-H1
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Read third time
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Passed by for the day
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Floor substitute printed 20109578D-H2 (Torian)
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Read second time
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Impact statement from DPB (SB172H1)
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Incorporates SB522
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Reported from Appropriations with substitute (22-Y 0-N)
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Committee substitute printed 20109092D-H1
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House committee, floor amendments and substitutes offered
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Subcommittee recommends reporting with substitute (8-Y 0-N)
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House subcommittee amendments and substitutes offered
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Impact statement from DPB (SB172ES1)
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Assigned App. sub: Health & Human Resources
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Referred to Committee on Appropriations
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Referred from Labor and Commerce
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Referred to Committee on Labor and Commerce
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Read first time
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Placed on Calendar
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Passed Senate (36-Y 4-N)
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Constitutional reading dispensed (40-Y 0-N)
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Printed as engrossed 20107408D-ES1
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Engrossed by Senate - committee substitute with amendments SB172ES1
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Committee amendments agreed to
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Reading of amendments waived
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Committee substitute agreed to 20107408D-S1
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Reading of substitute waived
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Read second time
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Constitutional reading dispensed (40-Y 0-N)
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Reported from Finance and Appropriations with amendments (11-Y 5-N)
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Rereferred to Finance and Appropriations
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Committee substitute printed 20107408D-S1
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Reported from Commerce and Labor with substitute (8-Y 7-N)
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Impact statement from DPB (SB172)
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Assigned C&L sub: Health Insurance
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Referred to Committee on Commerce and Labor
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Prefiled and ordered printed; offered 01/08/20 20101733D
Sponsors
- Barbara A. Favola · Primary
- Jennifer L. McClellan · Cosponsor
- Ryan T. McDougle · Cosponsor
- Jennifer B. Boysko · Cosponsor
- Bryce E. Reeves · Cosponsor
- Jill Holtzman Vogel · Cosponsor
- Jennifer A. Kiggans · Cosponsor
- John S. Edwards · Cosponsor
- Siobhan S. Dunnavant · Cosponsor
- Amanda F. Chase · Cosponsor
Sponsorship breakdown
Export CSV (upgrade) →1 sponsors · 9 co-sponsors · 138 not signed on · 8 voted No
Sponsors (1)
Co-sponsors (9)
Not signed on (138)
138 members have not signed on to this bill.
Show all 138 →"Not signed on" means a member has not sponsored or co-sponsored this bill — it does not imply opposition. Members flagged Voted No have a recorded No vote on this bill.
Votes
| Party | Yea | Nay | Present | Not Voting |
|---|---|---|---|---|
| Unaffiliated | 98 | 0 | 0 | 1 |
| Total | 98 | 0 | 0 | 1 |
| % of votes cast | 99% | 0% | 0% | 1% |
How each member voted (99)
| Party | Yea | Nay | Present | Not Voting |
|---|---|---|---|---|
| Unaffiliated | 39 | 0 | 0 | 1 |
| Total | 39 | 0 | 0 | 1 |
| % of votes cast | 98% | 0% | 0% | 3% |
How each member voted (40)
| Party | Yea | Nay | Present | Not Voting |
|---|---|---|---|---|
| Unaffiliated | 22 | 0 | 0 | 0 |
| Total | 22 | 0 | 0 | 0 |
| % of votes cast | 100% | 0% | 0% | 0% |
How each member voted (22)
| Member | Party | Vote |
|---|---|---|
| Brewer, Emily M. | — | Yea |
| Aird, Lashrecse D. | — | Yea |
| Betsy B. Carr | — | Yea |
| Bulova, David L. | — | Yea |
| C.E. Cliff Hayes, Jr. | — | Yea |
| Cox, M. Kirkland | — | Yea |
| David A. Reid | — | Yea |
| Davis, Glenn R. | — | Yea |
| Delores L. McQuinn | — | Yea |
| Fariss, C. Matthew | — | Yea |
| Hurst, Chris L. | — | Yea |
| James W. Morefield | — | Yea |
| Jones, Jerrauld C. "Jay" | — | Yea |
| Knight, Barry D. | — | Yea |
| Luke E. Torian | — | Yea |
| Paul E. Krizek | — | Yea |
| Plum, Kenneth R. | — | Yea |
| Robert S. Bloxom, Jr. | — | Yea |
| Rush, Nick | — | Yea |
| Sickles, Mark D. | — | Yea |
| Terry L. Austin | — | Yea |
| Tyler, Roslyn C. | — | Yea |
| Party | Yea | Nay | Present | Not Voting |
|---|---|---|---|---|
| Unaffiliated | 8 | 0 | 0 | 1 |
| Total | 8 | 0 | 0 | 1 |
| % of votes cast | 89% | 0% | 0% | 11% |
How each member voted (9)
| Member | Party | Vote |
|---|---|---|
| Brewer, Emily M. | — | Yea |
| Betsy B. Carr | — | Yea |
| C.E. Cliff Hayes, Jr. | — | Yea |
| Cox, M. Kirkland | — | Yea |
| Fariss, C. Matthew | — | Yea |
| Jones, Jerrauld C. "Jay" | — | Yea |
| Luke E. Torian | — | Not Voting |
| Paul E. Krizek | — | Yea |
| Sickles, Mark D. | — | Yea |
Roll call published as PDF — view source.
| Party | Yea | Nay | Present | Not Voting |
|---|---|---|---|---|
| Unaffiliated | 40 | 0 | 0 | 0 |
| Total | 40 | 0 | 0 | 0 |
| % of votes cast | 100% | 0% | 0% | 0% |
How each member voted (40)
| Party | Yea | Nay | Present | Not Voting |
|---|---|---|---|---|
| Unaffiliated | 36 | 4 | 0 | 0 |
| Total | 36 | 4 | 0 | 0 |
| % of votes cast | 90% | 10% | 0% | 0% |
How each member voted (40)
| Party | Yea | Nay | Present | Not Voting |
|---|---|---|---|---|
| Unaffiliated | 11 | 5 | 0 | 0 |
| Total | 11 | 5 | 0 | 0 |
| % of votes cast | 69% | 31% | 0% | 0% |
How each member voted (16)
| Member | Party | Vote |
|---|---|---|
| McClellan, Jennifer L. | — | Yea |
| Barker, George L. | — | Nay |
| David W. Marsden | — | Nay |
| Ebbin, Adam P. | — | Nay |
| Edwards, John S. | — | Yea |
| Hanger, Emmett W., Jr. | — | Yea |
| Howell, Janet D. | — | Yea |
| L. Louise Lucas | — | Yea |
| Mamie E. Locke | — | Yea |
| Newman, Stephen D. | — | Nay |
| Norment, Thomas K., Jr. | — | Yea |
| Petersen, J. Chapman | — | Nay |
| R. Creigh Deeds | — | Yea |
| Ruff, Frank M., Jr. | — | Yea |
| Saslaw, Richard L. | — | Yea |
| Vogel, Jill Holtzman | — | Yea |
| Party | Yea | Nay | Present | Not Voting |
|---|---|---|---|---|
| Unaffiliated | 8 | 7 | 0 | 0 |
| Total | 8 | 7 | 0 | 0 |
| % of votes cast | 53% | 47% | 0% | 0% |
How each member voted (15)
| Member | Party | Vote |
|---|---|---|
| Spruill, Lionell, Sr. | — | Yea |
| Barker, George L. | — | Nay |
| Bell, John J. | — | Yea |
| David W. Marsden | — | Nay |
| Ebbin, Adam P. | — | Nay |
| Edwards, John S. | — | Yea |
| L. Louise Lucas | — | Yea |
| Lewis, Lynwood W., Jr. | — | Yea |
| Mark D. Obenshain | — | Nay |
| Mason, T. Montgomery "Monty" | — | Nay |
| Newman, Stephen D. | — | Nay |
| Norment, Thomas K., Jr. | — | Yea |
| R. Creigh Deeds | — | Yea |
| Saslaw, Richard L. | — | Yea |
| Scott A. Surovell | — | Nay |
Subjects
Frequently asked questions
- What does SB 172 do?
- 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.
- Who sponsors SB 172?
- SB 172 is sponsored by Barbara A. Favola, Jennifer L. McClellan, Ryan T. McDougle, Jennifer B. Boysko, Bryce E. Reeves, Vogel, Jill Holtzman, Kiggans, Jennifer A., Edwards, John S., Dunnavant, Siobhan S., and Chase, Amanda F..
- What is the current status of SB 172?
- This bill has been enacted into law. Introduced December 20, 2019. Enacted.
- Where can I track SB 172?
- Track SB 172 free on One Click Politics — get push/email alerts when it moves.
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