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An Act to amend and reenact §
38.2-4319
of the Code of Virginia and to amend the Code of Virginia by adding in Article 1 of Chapter 34 of Title 38.2 a section numbered
38.2-3407.23
, relating to health insurance; prohibited restrictions on in-network referrals.
Be it enacted by the General Assembly of Virginia:
1. That §
38.2-4319
of the Code of Virginia is amended and reenacted and the Code of Virginia is amended by adding in Article 1 of Chapter 34 of Title 38.2 a section numbered
38.2-3407.23
as follows:
§
38.2-3407.23
. Prohibited restrictions on in-network referrals.
A. As used in this section:
"Carrier" has the same meaning as provided in §
38.2-3407.15
. "Carrier" includes any entity administering a policy or plan providing health insurance coverage to state employees pursuant to §
2.2-2818
.
"Health plan" has the same meaning as provided in §
38.2-3407.15
. "Health plan" includes any policy or plan providing health insurance coverage to state employees pursuant to §
2.2-2818
.
"In-network" means a provider that has contracted with a carrier or a carrier's contractor or subcontractor to provide health care services to enrollees and be reimbursed by the carrier at a contracted rate as payment in full for the health care services, including applicable cost-sharing requirements.
B. No carrier, in the provision of individual or group accident and sickness insurance, including any health benefit plan, shall prohibit an in-network provider from referring any enrollee or specimen to any in-network clinical laboratory or in-network pathology service provider under the terms of the health plan unless such referral would constitute a violation of the Practitioner Self-Referral Act (§
54.1-2410
et seq.) or 42 U.S.C. § 1320a-7b.
C. The Commission shall have no jurisdiction to adjudicate individual controversies arising out of this section.
§
38.2-4319
. Statutory construction and relationship to other laws.
A. No provisions of this title except this chapter and, insofar as they are not inconsistent with this chapter, §§
38.2-100
,
38.2-136
,
38.2-200
,
38.2-203
,
38.2-209
through
38.2-213
,
38.2-216
,
38.2-218
through
38.2-225
,
38.2-229
,
38.2-232
,
38.2-305
,
38.2-316
,
38.2-316.1
,
38.2-316.2
,
38.2-322
,
38.2-325
,
38.2-326
,
38.2-400
,
38.2-402
through
38.2-413
,
38.2-500
through
38.2-515
,
38.2-600
through
38.2-629
, Chapter 9 (§
38.2-900
et seq.), §§
38.2-1016.1
through
38.2-1023
,
38.2-1057
, and
38.2-1306.1
, Article 2 (§
38.2-1306.2
et seq.), §
38.2-1315.1
, and Articles 3.1 (§
38.2-1316.1
et seq.), 4 (§
38.2-1317
et seq.), 5 (§
38.2-1322
et seq.), 5.1 (§
38.2-1334.3
et seq.), and 5.2 (§
38.2-1334.11
et seq.) of Chapter 13, Articles 1 (§
38.2-1400
et seq.), 2 (§
38.2-1412
et seq.), and 4 (§
38.2-1446
et seq.) of Chapter 14, Chapter 15 (§
38.2-1500
et seq.), Chapter 17 (§
38.2-1700
et seq.), §§
38.2-1800
through
38.2-1836
,
38.2-3401
,
38.2-3405
,
38.2-3405.1
,
38.2-3406.1
,
38.2-3407.2
through
38.2-3407.6:1
,
38.2-3407.9
through
38.2-3407.20
,
38.2-3411
,
38.2-3411.2
,
38.2-3411.3
,
38.2-3411.4
,
38.2-3412.1
,
38.2-3414.1
,
38.2-3418.1
through
38.2-3418.19
,
38.2-3418.21
,
38.2-3418.22
,
38.2-3419.1
, and
38.2-3430.1
through
38.2-3454
, Articles 8 (§
38.2-3461
et seq.) and 9 (§
38.2-3465
et seq.) of Chapter 34, §
38.2-3500
, subdivision 13 of §
38.2-3503
, subdivision 8 of §
38.2-3504
, §§
38.2-3514.1
,
38.2-3514.2
,
38.2-3522.1
through
38.2-3523.4
,
38.2-3525
,
38.2-3540.1
,
38.2-3540.2
,
38.2-3541.2
,
38.2-3542
, and
38.2-3543.2
, Article 5 (§
38.2-3551
et seq.) of Chapter 35, Chapter 35.1 (§
38.2-3556
et seq.), §
38.2-3610
, Chapter 52 (§
38.2-5200
et seq.), Chapter 55 (§
38.2-5500
et seq.), Chapter 58 (§
38.2-5800
et seq.), Chapter 65 (§
38.2-6500
et seq.), and Chapter 66 (§
38.2-6600
et seq.) shall be applicable to any health maintenance organization granted a license under this chapter. This chapter shall not apply to an insurer or health services plan licensed and regulated in conformance with the insurance laws or Chapter 42 (§
38.2-4200
et seq.) except with respect to the activities of its health maintenance organization.
B. For plans administered by the Department of Medical Assistance Services that provide benefits pursuant to Title XIX or Title XXI of the Social Security Act, as amended, no provisions of this title except this chapter and, insofar as they are not inconsistent with this chapter, §§
38.2-100
,
38.2-136
,
38.2-200
,
38.2-203
,
38.2-209
through
38.2-213
,
38.2-216
,
38.2-218
through
38.2-225
,
38.2-229
,
38.2-232
,
38.2-322
,
38.2-325
,
38.2-400
,
38.2-402
through
38.2-413
,
38.2-500
through
38.2-515
, and
38.2-600
through
38.2-629
, Chapter 9 (§
38.2-900
et seq.), §§
38.2-1016.1
through
38.2-1023
,
38.2-1057
, and
38.2-1306.1
, Article 2 (§
38.2-1306.2
et seq.), §
38.2-1315.1
, Articles 3.1 (§
38.2-1316.1
et seq.), 4 (§
38.2-1317
et seq.), 5 (§
38.2-1322
et seq.), 5.1 (§
38.2-1334.3
et seq.), and 5.2 (§
38.2-1334.11
et seq.) of Chapter 13, Articles 1 (§
38.2-1400
et seq.), 2 (§
38.2-1412
et seq.), and 4 (§
38.2-1446
et seq.) of Chapter 14, §§
38.2-3401
,
38.2-3405
,
38.2-3407.2
through
38.2-3407.5
,
38.2-3407.6
,
38.2-3407.6:1
,
38.2-3407.9
,
38.2-3407.9:01
, and
38.2-3407.9:02
, subsection E of §
38.2-3407.10
, §§
38.2-3407.10:1
,
38.2-3407.11
,
38.2-3407.11:3
,
38.2-3407.13
,
38.2-3407.13:1
,
38.2-3407.14
,
38.2-3407.23
,
38.2-3411.2
,
38.2-3418.1
,
38.2-3418.2
,
38.2-3418.16
,
38.2-3419.1
,
38.2-3430.1
through
38.2-3437
, and
38.2-3500
, subdivision 13 of §
38.2-3503
, subdivision 8 of §
38.2-3504
, §§
38.2-3514.1
,
38.2-3514.2
,
38.2-3522.1
through
38.2-3523.4
,
38.2-3525
,
38.2-3540.1
,
38.2-3540.2
,
38.2-3541.2
,
38.2-3542
, and
38.2-3543.2
, Chapter 52 (§
38.2-5200
et seq.), Chapter 55 (§
38.2-5500
et seq.), Chapter 58 (§
38.2-5800
et seq.), Chapter 65 (§
38.2-6500
et seq.), and Chapter 66 (§
38.2-6600
et seq.) shall be applicable to any health maintenance organization granted a license under this chapter. This chapter shall not apply to an insurer or health services plan licensed and regulated in conformance with the insurance laws or Chapter 42 (§
38.2-4200
et seq.) except with respect to the activities of its health maintenance organization.
C. Solicitation of enrollees by a licensed health maintenance organization or by its representatives shall not be construed to violate any provisions of law relating to solicitation or advertising by health professionals.
D. A licensed health maintenance organization shall not be deemed to be engaged in the unlawful practice of medicine. All health care providers associated with a health maintenance organization shall be subject to all provisions of law.
E. Notwithstanding the definition of an eligible employee as set forth in §
38.2-3431
, a health maintenance organization providing health care plans pursuant to §
38.2-3431
shall not be required to offer coverage to or accept applications from an employee who does not reside within the health maintenance organization's service area.
F. For purposes of applying this section, "insurer" when used in a section cited in subsections A and B shall be construed to mean and include "health maintenance organizations" unless the section cited clearly applies to health maintenance organizations without such construction.