|Introduced in House||Passed House||Introduced in Senate||Passed Senate||Became Law|
Health care services; explanation of benefits.
Requires health carriers and Medicaid managed care organizations to provide an explanation of benefits to covered persons or recipients. The measure requires the State Corporation Commission to adopt regulations that establish alternative methods of delivery of the explanation of benefits that permit the receipt of an explanation of benefits by an alternative method, provided that such alternative method is in compliance with the provisions of federal regulations regarding the right to request privacy protection for protected health information. The measure requires health carriers and Medicaid managed care organizations to take all reasonable actions to ensure that their internal processes and systems prohibit the identification or description of sensitive health care services in their explanations of benefits. The measure requires a health carrier that requires a covered person to make a request for confidential communications in writing in accordance with federal law to accept the form of the explanation of benefits approved by the Commission. The measure also requires the Commission to define "sensitive health care services." The measure will take effect 90 days after the Commission has adopted the required regulations. The measure is a recommendation of the Joint Commission on Health Care.
Be it enacted by the General Assembly of Virginia:
� 32.1-330.2. Medicaid managed care programs; program information documents; plain language required.
A. Whenever medical assistance services pursuant to this chapter are furnished through managed care programs, the Board of Medical Assistance Services shall require that all program information documents furnished recipients covered thereunder shall be written in nontechnical, readily understandable language, using words of common, everyday usage.
B. Each sponsor or administrator of any such managed care
program shall test the readability of its program information documents by use
of the Flesch Readability Formula, as set forth in Rudolf Flesch, The Art of
Readable Writing (1949, as revised 1974), and no program information document
shall be used unless it achieves a Flesch total readability score of
40 or more. The requirements of this subsection shall not apply to language
which that is mandated by federal or state laws, regulations,
C. All program information documents within the scope of this
section, and all amendments thereto, shall be filed with the Department of
Medical Assistance Services in advance of their use and distribution, accompanied
by certificates setting forth the Flesch scores and certifying compliance with
the requirements of this section. Any program information document
that is exempt from the requirements of subsection B shall be accompanied
by a documentation of the federal or state law, regulation, or agency
mandate that authorizes the exemption.
D. For the purpose of this section, the term "program
information documents" means all forms, brochures, handbooks, or
other documentation (i) provided recipients covered under Medicaid managed care
, and (ii) describing the programs medical care coverages and
the rights and responsibilities of recipients covered thereunder. Further, the
term "recipient" shall include includes potential
recipients and recipients.
E. Each contract between the Department and a sponsor or administrator that contracts with the Department to provide services through the Medicaid managed care program shall require that the sponsor or administrator provide each recipient covered under its program with an explanation of benefits that complies with the requirements of � 38.2-3407.4.
� 38.2-3407.4. Explanation of benefits.
A. As used in this section:
"Carrier" means any insurer issuing an accident and sickness insurance policy, corporation issuing subscription contracts, health maintenance organization, or managed care organization.
"Explanation of benefits" means a form provided by a carrier that explains the amounts covered under a policy or plan and shows the amounts payable by a covered person or recipient to a health care provider.
"Managed care organization" means a sponsor or administrator that contracts with the Department of Medical Assistance Services to provide services through the Medicaid managed care program.
"Sensitive health care services" includes health care services that a covered person or recipient may reasonably be expected to prefer not be disclosed to another person, such as services related to reproductive health, mental health, or substance use disorders, provided that the specific health care services that constitute sensitive health care services shall be as specified in regulations adopted by the Commission that define sensitive health care services as required by subdivision D 4.
insurer issuing an accident and sickness
insurance policy, a corporation issuing subscription contracts, and each health
maintenance organization carrier shall file for approval
provide to covered persons or recipients an explanation of benefits
forms in a form approved by the Commission. These explanation of
benefit forms shall be subject to the requirements of � 38.2-316 or �
38.2-4306, as applicable. B. C. The explanation of benefits shall
accurately and clearly set forth the benefits payable under the contract or
program. C. D. The Commission may issue shall
adopt regulations to establish that:
1. Establish standards for the accuracy and clarity of
the information presented in an explanation of benefits
. D. The term "explanation of benefits" as used in
this section shall include any form provided by an insurer, health services
plan or health maintenance organization which explains the amounts covered
under a policy or plan or shows the amounts payable by a covered person to a
health care provider;
2. Establish alternative methods of delivery of the explanation of benefits that permit (i) a subscriber who is legally authorized to consent to care for a covered person or recipient, (ii) a covered person or recipient who is legally authorized to consent to that covered persons or recipients own care, or (iii) another party who has the exclusive legal authorization to consent to care for the covered person or recipient to receive the explanation of benefits by an alternative method, provided that such alternative method is in compliance with the provisions of 45 C.F.R. � 164.522 regarding the right to request privacy protection for protected health information;
3. Require the carrier to take all reasonable actions to ensure that its internal processes and systems prohibit the identification or description of sensitive health care services in its explanations of benefits; and
4. Define "sensitive health care services." In developing that definition, the Commission shall consider the recommendations of the National Committee on Vital and Health Statistics and similar regulations in other states and shall consult with experts in fields including infectious disease, reproductive and sexual health, domestic violence and sexual assault, mental health, and substance use disorders.
E. A carrier that requires a covered person to make a request for confidential communications in writing in accordance with 45 C.F.R. � 164.522(b) shall accept the form of the explanation of benefits approved by the Commission.
2. That by [
November ] 1, 2020, the State
Corporation Commission shall commence a proceeding in accordance with its rules
of practice and procedure for the adoption of the regulations that are required
by subsection D of � 38.2-3407.4 of the Code of Virginia as amended and
reenacted by this act.
3. That the provisions of the first enactment of this act shall become effective 90 days after the date the State Corporation Commission enters a final order adopting the regulations pursuant to the proceeding commenced pursuant to the second enactment of this act.
|01/28/2020||Senate||Senate: Referred to Committee on Commerce and Labor|
|01/27/2020||House||House: VOTE: (99-Y 0-N)|
|01/24/2020||House||House: Printed as engrossed 20104454D-E|
|01/21/2020||House||House: Reported from Labor and Commerce with amendment (20-Y 0-N)|
|01/07/2020||House||House: Prefiled and ordered printed; offered 01/08/20 20104454D|
|01/07/2020||House||House: Referred to Committee on Labor and Commerce|