We thank you for the opportunity to submit testimony in support of HB 2021. This bill represents a good-faith effort of providers to address updates to the Commonwealth’s Fairness in Carrier Business Practices Act. This bill looks to preclude insurers from unilaterally amending provider contracts within a year of a contract’s execution. Operating as a small business under a partnership with 15 community-based, local radiologists in non-hospital-based facilities in Northern Virginia and Roanoke, we have experienced unilateral and arbitrary decisions being made by major insurers that have threatened our ability to continue our high-value services. As many physician practices have been battered by the impacts of the COVID-19 pandemic, these unilateral contracting amendments only add to increased administrative costs and make difficult financial situations worse. If a provider would choose to terminate a contract with a payer, their patients would face fewer options in the marketplace and increased out-of-pocket costs. With respect to the “surprise” and out-of-network billing discussions, we believe experiences with major insurers exhibit the elemental concerns of independent physicians with the current insurer-controlled process. Independent providers, like Insight Imaging and our radiologists, are often left with no recourse but to explore going out-of-network or exiting the marketplace altogether. Indeed, many insurers are reluctant to offer the basis for cuts or even entertain discussions regarding the significant impact on our patients. This directly affects the continuity of care and patient financial responsibility and, over the long term, innovation and competition. Additionally, this bill looks to establish a minimum timeframe for providers to submit claims for payment and ensures that complaints are resolved in a transparent, efficient manner. We appreciate your time and consideration of this legislation, and let us know if we can provide any additional information. Zachary Brunnert Director - State Legislative Policy

Chairman Heretick and Members of the Committee, AARP Virginia, on behalf of our 1 million members and all older Virginians statewide, urges you to vote no on HB2033, which creates an Association Health Plan (AHP). Expanding the availability of these plans would likely cause higher premiums in the Affordable Care Act (ACA) marketplace due to healthy individuals being drawn to them and leaving a sicker, higher cost group in the risk pool. This scenario would hurt all Virginians in the marketplace and particularly those who rely on comprehensive services offered by ACA compliant plans. Older Virginians, those ages 50-64, are particularly vulnerable to the proliferation of these plans because they all allow insurers to charge exorbitant rates just because of someone’s age. In the case of HB2033, age rating of 4:1 is explicitly allowed. Though AARP prefers true community rating, the ACA ensured that older Virginians could not be charged more than three times the amount of any other individual. Prior to this there was no regulation on how much more an older Virginian could be charged for their premiums. This consumer protection is essential to ensuring access to quality, affordable insurance for those age 50-64. Deregulation of these plans will lead to lower health coverage standards, high out of pocket costs for consumers, and higher premiums in the ACA individual marketplace. This would be a step in the wrong direction for Virginia and would undermine key ACA protections. For these reasons, we respectfully ask you to please vote no on HB2033. Respectfully submitted, Natalie Snider AARP Virginia State Advocacy Director 804-344-3063 nsnider@aarp.org

Thank you for the opportunity to share the views of The Leukemia and Lymphoma Society (LLS) on HB 2033. We ask the committee to please oppose this bill. We oppose HB 2033, and do so for one main reason. This is not the way to solve what we all agree is the problem: ensuring affordable health insurance coverage is available for Virginians, specifically those purchasing individual and small group coverage. AHPs are not the right solution to this problem. They are, however, a key component of years-long attempts to undermine the ACA . The Market Stability and Reinsurance Work Group, in their December 2020 report to this committee, noted “In 2018, the Trump administration unveiled a cornerstone of the administration’s health care policy, to expand Association Health Plans as an ACA alternative.” In fact, Virginia is one of eleven states and the District of Columbia who is currently suing to overturn the Trump Administration’s proposed rule. It is this rule that HB 2033 relies on to allow these plans’ expansion. Codifying their creation in Virginia code now would work to further undercut the ACA patient protections and complicate legal challenges to the federal rule. For several sessions, there have been efforts to all AHPs to proliferate. We opposed those efforts in the past, and we oppose this one. However, it is important to note that this year’s bill is significantly different than prior years’ proposals. As drafted, the plans created in HB 2033 are NOT insurance coverage. This allows them to avoid complying with current state regulation and the patient protections of the Affordable Care Act. From HB 2033, lines 188-192: “the policy shall not be considered to be insurance under this title or any other provision of law”. These bills include what appears to be protection for people with pre-existing conditions, but the referenced code is only applicable to insurance policies. By specifically defining these plans as not being insurance, there is no clear legal authority for the Bureau of Insurance to regulate them, despite conflicting language in the bill claiming to do so. The Bureau notes this in their impact statement. HB 2033 poses risks to people who purchase coverage on the individual and small group markets. These plans could market to and attract younger, healthier individuals, pulling them out of the marketplace, and likely leading to higher premiums for everyone else – and an older, sicker risk pool in the VA marketplace. These bills would allow AHPs to charge older adults 4 times as much for their premiums, a practice that’s more limited in ACA plans. Additionally, the plans proposed in HB 2033 would not be limited to realtors in Virginia. The bill would allow these plans to be sold into other states, as long as just one member lives in Virginia. If this bill passes, there is nothing to stop another group from seeking the same authorization to create their own plan, further fracturing and destabilizing the ACA marketplace. Instead, of seeking to undermine let’s help all Virginians by implementing a reinsurance program. Reinsurance could reduce premiums in the individual health insurance market up to 20% without undermining ACA consumer protections or destabilizing the individual market. We urge the committee to instead pursue reinsurance, and lower premiums for EVERYONE. We strongly urge you to vote no on HB 2033. Sincerely, Sarah Balog Regional Director of Government Affairs LLS

The Virginia Hemophilia Foundation, the Hemophilia Assn of the Capital Area, and the Virginia Diabetes Council are opposed to HB 2033 (Hurst) for the following reasons: (1) potential diminution of the risk pool in the healthcare marketplace; (2) pre-existing disease conditions can be considered as a disqualifier for association health plans; (3) noncompliance with the provisions of the ACA.

On behalf of the American Lung Association in Virginia and the patients we serve with lung disease and on behalf of all the Virginians who depend on access to adequate, affordable and accessible health coverage. Lung Disease patients including those with asthma, lung cancer, and acute bronchitis have unique health needs. Comprehensive coverage is vital to ensure all lung disease patients have access to the medications, treatments and specialists they require to live. We ask that you keep the needs of these Virginians in mind during the upcoming Subcommittee #2 meeting, specifically regarding HB 2033 by Delegate Hurst. The American Lung Association strongly opposes House Bill 2033. HB 2033 creates plans that are defined as not insurance coverage. As drafted the plans created are not required to comply with current state regulation and the patient protections of the Affordable Care Act and while they may appear to provide protections for people with pre-existing conditions, the reference code is only applicable to insurance policies HB 2033 puts people who purchased plans on the individual market at risk. These plans could market to and attract younger, healthier individuals, pulling them out of the marketplace, leading to potential higher premiums for those that remain, essentially cherry-picking healthier consumers and allowing sicker patients to remain in the marketplace. This bill would allow AHPs to charge older adults 4 times as much for their premiums, which is much more limited in ACA complaint plans. HB 2033 would be available to groups beyond Realtors in Virginia. These plans could be sold in other states, as long as just one member lives in Virginia. There is nothing prohibiting another group to seek the same authorization and create their own plan, therefore potentially destabilizing the ACA marketplace These plans pose risks to patients and consumers and the Lung Association is asking that you PLEASE VOTE NO on HB 2033. The American Lung Association thanks you for the opportunity to share our comments on this proposed piece of legislation. We hope that you will act to protect patients with lung disease and all those who rely on adequate, affordable and accessible health care.

The National Multiple Sclerosis Society expresses serious concern regarding HB 2033 and the association health plans (AHPs) it would establish in Virginia. While the Society acknowledges the need for more affordable health insurance, we strongly condemn AHPs as unable to meet the needs of people with complex, high-cost, chronic conditions like multiple sclerosis, and fear these plans will fragment and destabilize the ACA marketplace. Importantly, according to the language in this bill, these AHPs would be able to skirt Bureau of Insurance regulation and important patient protections provided by the ACA. We respectfully urge members to oppose HB 2033. Like all organizations representing the interests of people with special health needs, we have a unique perspective on what individuals and families need to manage their conditions. Multiple sclerosis (MS) is an unpredictable, often disabling disease of the central nervous system that disrupts the flow of information within the brain, and between the brain and body. Symptoms vary from person to person and range from numbness and tingling to walking difficulties, fatigue, dizziness, pain, depression, blindness, and paralysis. The progress, severity, and specific symptoms of MS in any one person cannot yet be predicted, but advances in research and treatment are leading to better understanding and moving us closer to a world free of MS. Access to affordable, high-quality health coverage is essential for people living with MS to get the care and treatment they need to live their best lives. Unfortunately, the high cost of insurance places adequate coverage out of reach for far too many. However, AHPs are not a viable solution to the problem of high-cost coverage, and pose serious risks for people living with MS and the ACA marketplace. As drafted, the AHPs created by this legislation are defined not as insurance coverage, allowing them to skirt state regulation and the patient protections of the ACA (HB 2033, lines 188-192). While this bill may appear to include protection for people living with MS, the referenced code is only applicable to insurance policies. In defining these plans as not insurance, there is no clear legal authority for the Bureau of Insurance to regulate these plans, despite confusing and contradictory language in the bill claiming to do so - as noted by the Bureau’s impact statement on HB 2033. In addition, this bill poses serious risk to people who purchase plans on the individual market. These AHPs could be marketed to and attract younger individuals with fewer health care costs, pulling them out of the ACA marketplace. This will likely lead to higher premiums and to an older, sicker risk pool in the state marketplace. Thank you for the opportunity to share our concerns regarding HB 2033. We respectfully urge members to oppose this bill.

I am writing to express Virginia Poverty Law Center’s opposition to HB233, the expansion of Association Health Plans (AHPs) to real estate salespersons. AHPs can skirt important ACA consumer protections and target younger and healthier enrollees. They can discriminate against older workers by charging them 4 times more than younger ones. The ACA limits the age rating ratio to 3:1. AHPs can also discriminate by using non-ACA rating factors such as their own geographical ratings and drug utilization. This hurts older and sicker individuals and those living in geographic areas deemed less healthy (often poorer communities). These practices split the ACA risk pool and increase rates in the individual and small group markets. Additionally, this bill is ambiguous. Are AHPs insurance or not? The bill says both. Lines 188-192 say “shall not be considered to be insurance under this title or any other provision of law.” However, the legislation is also written into Title 38 (Virginia’s insurance code) and refers to many insurance provisions in Title 38. Is there any regulatory oversight of these plans? If AHPs are not insurance and not subject to Virginia’s insurance laws, then the SCC cannot regulate the plans. The language that the SCC can impose any insurance requirement “as it deems appropriate” (Lines 190-192) does not address this contradiction. In fact, the SCC Fiscal Impact Statement states, “If the coverage is to be subject to the Commission’s regulatory authority as stated in the bill, the paragraph on lines 188-192 should be deleted.” Expanding these plans now is incredibly untimely. The Biden administration has committed to addressing affordability issues faced by those who are ineligible for subsidized coverage. At the state level, a new reinsurance program is the equitable policy choice for reducing health insurance premiums by up to 20%. Reinsurance would benefit all ineligible for subsidies, not just realtors, keep the single risk pool intact, and not undermine important ACA consumer protections. For these reasons, I urge you to vote no on HB2033.

RE: Oppose HB 2033, Health insurance; association health plan for real estate salespersons Dear Chairman Heretick and other members of the Committee: I am writing to you to urge you to oppose HB 2033, which would have negative impacts on the marketplace—and consequently on small businesses that already struggle with healthcare costs. Ensuring strong and robust individual and small group healthcare marketplaces is vitally important to Virginia’s entrepreneurs because this is essential to keeping costs down for business owners and their employees. Unfortunately, HB 2033 would create a less protected insurance market that would only drive up premiums. For instance, as drafted, HB 2033 is not defined as insurance coverage, meaning it does not have to comply with state requirements or patient protection under the Affordable Care Act (ACA). In fact, the legislation’s premium allowable rating is a 4:1 ratio, meaning an insurer could charge older adults up to four times the normal premium amount. This does not comply with the Affordable Care Act’s guidelines of a 3:1 ratio. What’s more, this bill would not be limited to realtors in Virginia. The bill would allow these plans to be sold in other states, so long as one member lives in Virginia, further incenting other groups to recreate this model, resulting in a destabilized ACA marketplace. These plans put small businesses at risk since they are not treated like traditional insurance, which limits the state’s ability to protect those with pre-existing conditions. Though these plans might make it easier for younger and/or healthier employees to purchase coverage through association health plans, the tradeoff is small employers with older and/or sicker workers would end up paying more. Furthermore, consumers who would need robust healthcare would eventually be priced out as well. Association health plans are dangerous additions to the marketplace that undermine the small group market and could raise costs for small business owners. I strongly urge you to oppose HB 2033. Sincerely, Awesta Sarkash Small Business Majority

The Roanoke Regional Chamber supports efforts that expand the prevalence of association health plans. Please support HB 2033.