dcrodriguez/Code-of-Virginia huggingface dataset:
Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3443. Choice of a health care professional.
A. Notwithstanding any provision of § 38.2-3407.11, 38.2-4312.3, or any other section of this title to the contrary, if a health carrier providing individual or group health insurance coverage requires or provides for the designation by a covered person of a participating primary care health care professional, the health carrier shall permit each covered person to designate any participating primary care health care professional who is available to accept the covered person. For a child, a participating health care professional who specializes in pediatrics and is available to accept the child may be designated as the child's primary care health care professional.

B. If a health carrier provides for obstetrical or gynecological care and requires the designation by a covered person of a participating primary care health care professional, the health carrier shall not require any person's prior authorization or referral in the case of a female covered person who seeks coverage for obstetrical or gynecological care provided by a participating health care professional who specializes in obstetrics or gynecology. The provision of obstetrical and gynecological care, and the ordering of related items and services, shall be treated the same as an authorization from a primary care health care professional.

C. A health carrier shall provide notice to a covered person of the terms and conditions of the plan related to the designation of a participating health care professional.

1. Such notice shall be included whenever the health carrier provides a covered person with a summary plan description, policy, certificate, or contract of health insurance.

2. The health carrier may use the model language found in 45 C.F.R. § 147.138(a)(4)(iii) for such notice.

D. This section shall apply to any health carrier providing individual or group health insurance coverage, except for any grandfathered plan.

2011, c. 882.

Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3444. Preexisting condition exclusions.
A. Notwithstanding any provision of § 38.2-508.1, 38.2-3432.3, 38.2-3438, 38.2-3503, 38.2-3520, or any other section of this title to the contrary, a health carrier providing individual or group health insurance coverage shall not limit or exclude coverage for an individual by imposing a preexisting condition exclusion on that individual.

B. A health carrier that offers individual health insurance coverage may offer coverage continuously throughout the year or during an open enrollment period.

C. This section shall apply to any health carrier providing individual or group health insurance coverage, including a grandfathered plan for group health insurance coverage, but not including a grandfathered plan for individual health insurance coverage.

2011, c. 882; 2013, cc. 136, 210, 751.
Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3445. Patient access to emergency services.
A. Notwithstanding any provision of § 38.2-3407.11, 38.2-4312.3, or any other section of this title to the contrary, if a health carrier providing individual or group health insurance coverage provides any benefits with respect to services in an emergency department of a hospital, the health carrier shall provide coverage for emergency services:

1. Without the need for any prior authorization determination, regardless of whether the emergency services are provided on an in-network or out-of-network basis;

2. Without regard to the final diagnosis rendered to the covered person or whether the health care provider furnishing the emergency services is a participating health care provider with respect to such services;

3. If such services are provided out-of-network, without imposing any administrative requirement or limitation on coverage that is more restrictive than the requirements or limitations that apply to such services received from an in-network provider;

4. If such services are provided out-of-network, the health carrier shall pay the out-of-network provider in accordance with § 38.2-3445.01 less any cost-sharing requirement. Any such cost-sharing requirement shall not exceed the cost-sharing requirement that would apply if such services were provided in-network as provided in § 38.2-3445.01; and

5. Without regard to any term or condition of such coverage other than the exclusion of or coordination of benefits or an affiliation or waiting period.

B. Coverage for emergency services that are related to mental health services or substance abuse services, as those terms are defined in § 38.2-3412.1, shall be provided in accordance with the federal Mental Health Parity and Addiction Equity Act of 2008, P.L. 110-343, even where those requirements would not otherwise apply directly. Such emergency services may be rendered at a location other than the emergency department of a hospital, such as a behavioral health crisis service provider, as required.

2011, c. 882; 2020, cc. 1080, 1081; 2024, cc. 199, 360.
Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3445.03. Data sets for determining commercially reasonable payments.
A. The Commission shall contract with the nonprofit data services organization to establish a data set and business process to provide health carriers, health care providers, and arbitrators with data to assist in determining commercially reasonable payments and resolving payment disputes for out-of-network medical services rendered by health care providers.

B. Such data set and business protocols shall be (i) developed in collaboration with health carriers and health care providers and (ii) reviewed by the advisory committee established pursuant to § 32.1-276.7:1.

C. The data set shall provide the amounts for the services described in subsection A of § 38.2-3445.01. The data used to calculate the median in-network and out-of-network allowed amounts and the median billed charge amounts by geographic area, for the same or similar services, shall be drawn from commercial health plan claims and shall not include claims paid under Medicare or Medicaid or other claims paid on other than a fee-for-service basis. The 2020 data set shall be based upon the most recently available full calendar year of claims data. The data set for each subsequent year shall be adjusted by applying the Consumer Price Index-Medical Component as published by the Bureau of Labor Statistics of the U.S. Department of Labor to the previous year's data set.

2020, cc. 1080, 1081.
Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3445.05. Enforcement.
A. If the Commission has cause to believe that any health care provider has engaged in a pattern of potential violations of § 38.2-3445.01 with no corrective action, the Commission may submit information to the Board of Medicine or the Commissioner of Health for action. Prior to such submission, the Commission may provide the provider with an opportunity to cure the alleged violations or provide an explanation as to why the actions in question were not violations of § 38.2-3445.01.

B. If any health care provider has engaged in a pattern of potential violations of § 38.2-3445.01 with no corrective action, the Board of Medicine or the Commissioner of Health may levy a fine or cost recovery upon the health care provider and take other action as permitted under the authority of the Board of Medicine or Commissioner of Health. Upon completion of its review of any potential violation submitted by the Commission or initiated directly by an enrollee, the Board of Medicine or Commissioner of Health shall notify the Commission of the results of the review, including whether the violation was substantiated and any enforcement action taken as a result of a finding of a substantiated violation.

C. If a carrier has engaged in a pattern of substantiated violations of any provision of § 38.2-3445.01, the Commission may levy a fine or apply remedies authorized pursuant to Chapter 2 (§ 38.2-200 et seq.).

D. No carrier or provider shall initiate arbitration pursuant to § 38.2-3445.02 with such frequency as to indicate a general business practice.

2020, cc. 1080, 1081.
Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3445.06. Applicability of certain sections.
A. Except as provided in this section, the provisions of §§ 38.2-3445 through 38.2-3445.05 shall not apply to an entity providing or administering an employee welfare benefit plan, as defined in § 3(1) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1002(1), that is self-insured or self-funded with respect to such plan. Such an entity may elect to be subject to the provisions of §§ 38.2-3445 through 38.2-3445.06 in the same manner as applied to a health carrier by providing notice to the Commission annually, in a form and manner prescribed by the Commission, attesting to the plan's participation and agreeing to be bound by the provisions of §§ 38.2-3445 through 38.2-3445.06. Such entity shall amend the plan, policies, contracts, and other documents to reflect such election. In addition, the entity that elects to opt in pursuant to this section shall file current plan documentation confirming that the plan accepts the obligations of §§ 38.2-3445 through 38.2-3445.06 and attests that any amended plan documents will be filed with the Commission before the effective date of such amendments. The Commission shall post on its website a list of entities, including relevant plan information, that have elected to be subject to the provisions of §§ 38.2-3445 through 38.2-3445.06. The Commission shall update such list at least once per quarter.

B. The provisions of §§ 38.2-3445.01 and 38.2-3445.02 shall not apply to services when the provider's fees are subject to schedules or other monetary limitations under any other law, including the Virginia Workers' Compensation Act, and such sections shall not preempt any such law.

C. The provisions of §§ 38.2-3445 through 38.2-3445.05 shall apply to health coverage insurance offered to state employees pursuant to § 2.2-2818 and may apply to health insurance coverage offered to employees of local governments, local officers, teachers, and retirees, and the dependents of such employees, officers, teachers, and retirees pursuant to § 2.2-1204.

D. Except for its facilitation of arbitration pursuant to § 38.2-3445.02 and its role in any appeals process established pursuant to subsection J of § 38.2-3445.02, the Commission shall have no jurisdiction to resolve disputes arising out of § 38.2-3445.01.

E. Except for in a provider contract between a carrier and an in-network provider, no person shall waive, be required to waive, or require another person to waive the provisions of §§ 38.2-3445 through 38.2-3445.05.

2020, cc. 1080, 1081.

Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3445.07. Rules and regulations.
Pursuant to § 38.2-223, the Commission may adopt rules and regulations to implement and administer the provisions of §§ 38.2-3445 through 38.2-3445.06, including rules and regulations governing the arbitration process established in § 38.2-3445.02.

2020, cc. 1080, 1081.
Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3445.1. Repealed.
Repealed by Acts 2020, cc. 1080 and 1081, cl. 2, effective January 1, 2021.
Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3446. Applicability of federal law.
A. The provisions of Title I of the PPACA shall apply to any health carrier that delivers or issues for delivery individual or group health insurance coverage in the Commonwealth.

B. The Commission shall implement and enforce applicable provisions of such federal law in accordance with the provisions of this title.

2011, c. 882.
Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3448. Guaranteed availability.
A. Notwithstanding any provision of § 38.2-3430.3, 38.2-3436, or any other section of this title to the contrary, a health carrier offering a health benefit plan providing individual or group health insurance coverage shall issue such coverage to any eligible individual or employer in the Commonwealth that applies for such coverage. For purposes of this section, an "eligible individual" means any individual eligible for either individual or group health insurance coverage in the Commonwealth.

B. A health carrier may restrict enrollment in a health benefit plan to open or special enrollment periods. The Commission may establish open enrollment periods applicable to all health benefit plans.

2013, c. 751.

Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3449. Prohibiting discrimination based on health status.
A. Notwithstanding any provision of § 38.2-508.5, 38.2-3431, 38.2-3432.3, 38.2-3521.1, 38.2-3522.1, 38.2-3540.2, 38.2-3551, 38.2-4109, or any other section of this title to the contrary, a health carrier offering a health benefit plan providing individual or group health insurance coverage shall not establish rules for eligibility, including continued eligibility, of any covered person to enroll under the terms of coverage based on any health status-related factor in relation to the covered person.

B. A health carrier shall not require any covered person as a condition of enrollment or continued enrollment under a health benefit plan to pay a premium or contribution that is greater than such premium or contribution for a similarly situated covered person enrolled in the plan on the basis of any health status-related factor in relation to the covered person.

2013, c. 751.
Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3449.1. Prohibited discrimination based on gender identity or status as a transgender individual.
A. As used in this section:

"Gender identity" means an individual's internal sense of gender, which may be male, female, neither, or a combination of male and female and which may be different from an individual's sex assigned at birth.

"Medically necessary transition-related care" means any medical treatment prescribed by a licensed physician for treatment of gender dysphoria and includes (i) outpatient psychotherapy and mental health services for gender dysphoria and associated co-morbid psychiatric diagnoses; (ii) continuous hormone replacement therapy; (iii) outpatient laboratory testing to monitor continuous hormone therapy; and (iv) gender reassignment surgeries.

"Transgender individual" means an individual whose gender identity is different from the sex assigned to that individual at birth.

B. A health carrier offering a health benefit plan providing individual or group health insurance coverage shall:

1. Provide coverage under the health benefit plan without discrimination on the basis of gender identity or status as a transgender individual; and

2. Treat covered individuals consistent with their gender identity.

C. A health carrier offering a health benefit plan providing individual or group health insurance coverage shall not deny or limit coverage or impose additional cost sharing or other limitations or restrictions on coverage, under a health benefit plan for health care services that are ordinarily or exclusively available to covered individuals of one sex, to a transgender individual on the basis of the fact that the individual's sex assigned at birth, gender identity, or gender otherwise recorded is different from the one to which such health services are ordinarily or exclusively available.

D. An individual shall not be subjected to discrimination under a health benefit plan on the basis of gender identity or being a transgender individual, including by being denied coverage of medically necessary transition-related care.

E. Nothing in this section is intended to determine, or restrict a health carrier from determining, whether a particular health care service is medically necessary or otherwise meets applicable coverage requirements in any individual case.

F. A health carrier shall not require any individual, as a condition of enrollment or continued enrollment under a health benefit plan, to pay a premium or contribution that is greater than such premium or contribution for a similarly situated covered person enrolled in the plan on the basis of the covered person's gender identity or being a transgender individual.

G. Health carriers shall assess medical necessity according to nondiscriminatory criteria that are consistent with current medical standards.

2020, c. 844.
Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3450. Genetic information and testing.
A. A health carrier offering a health benefit plan providing individual and group health insurance coverage shall not adjust premium or contribution amounts for a covered person under such plan on the basis of genetic information.

B. A health carrier shall not request or require a covered person to undergo a genetic test, or require or purchase genetic information for underwriting purposes. A health carrier shall not request, require, or purchase genetic information with respect to any covered person prior to the covered person's enrollment under the health benefit plan.

C. Genetic information may be obtained under the following circumstances:

1. A health care professional who is providing health care services to a covered person may request that the covered person undergo a genetic test.

a. A health carrier may obtain and use the results of a genetic test in making a determination regarding payment of a claim.

b. A health carrier may request only the minimum amount of information necessary to accomplish the intended purpose.

2. A health carrier may request, but not require, that a covered person undergo a genetic test if all of the following conditions are met:

a. The request is made pursuant to research that complies with Part 46 of Title 45 of the Code of Federal Regulations or equivalent federal regulations and any applicable state or local law or regulation for the protection of human subjects in research;

b. The health carrier clearly indicates to the covered person, or in the case of a minor child, to the legal guardian of the child, to whom the request is made that:

(1) Compliance with the request is voluntary; and

(2) Noncompliance will have no effect on enrollment status or premium or contribution amounts;

c. No genetic information collected or acquired under this subsection shall be used for underwriting purposes;

d. The health carrier notifies the federal Secretary of Health and Human Services in writing that the health carrier is conducting activities pursuant to the exception provided in this subsection, including a description of all the activities conducted; and

e. The health carrier complies with such other conditions as the Secretary may by regulation require for activities conducted under this subsection.

D. Any reference in this section to genetic information concerning a covered person shall:

1. With respect to the covered person who is a pregnant woman, include genetic information of any fetus carried by the pregnant woman; and

2. With respect to a covered person utilizing an assisted reproductive technology, include genetic information of any embryo legally held by the covered person.

E. This section shall apply to any health carrier providing individual or group health insurance coverage, including any grandfathered plan.

2013, c. 751.
Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3451. Essential health benefits.
A. Notwithstanding any provision of law to the contrary, any person offering or providing a health benefit plan providing individual or small group health insurance coverage, including (i) catastrophic health insurance policies, and policies that pay on a cost-incurred basis; (ii) association health plans; and (iii) plans provided by a multiple-employer welfare arrangement, shall provide that such coverage includes essential health benefits. Nothing in this section shall require a health benefit plan providing large group health insurance coverage to provide coverage for essential health benefits in a manner that exceeds the requirements of the PPACA as of January 1, 2019. The essential health benefits package may also include associated cost-sharing requirements or limitations.

B. The provisions of subsection A requiring minimum essential pediatric oral health benefits shall be deemed to be satisfied for health benefit plans made available in the small group market or individual market in the Commonwealth outside an exchange, as defined in § 38.2-3455, issued for policy or plan years beginning on or after January 1, 2015, that do not include the minimum essential pediatric oral health benefits if the health carrier has obtained reasonable assurance that such pediatric oral health benefits are provided to the purchaser of the health benefit plan. The health carrier shall be deemed to have obtained reasonable assurance that such pediatric oral health benefits are provided to the purchaser of the health benefit plan if:

1. At least one qualified dental plan, as defined in § 38.2-3455, (i) offers the minimum essential pediatric oral health benefits and (ii) is available for purchase by the small group or individual purchaser; and

2. The health carrier prominently discloses, in a form approved by the Commission, at the time that it offers the health benefit plan that the plan does not provide the minimum essential pediatric oral health benefits.

2013, c. 751; 2014, cc. 307, 369; 2020, c. 1160; 2021, Sp. Sess. I, cc. 101, 102.

Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3452. Waiting periods.
Notwithstanding any provision of § 38.2-3436, 38.2-4216.1, or any other section of this title to the contrary, a health carrier offering a health benefit plan providing group health insurance coverage shall not apply any waiting period that exceeds 90 days.

2013, c. 751.
Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3454.1. Renewal of health benefit plans; special exception.
Notwithstanding any other provision of state law, a health carrier may renew any health benefit plan that would otherwise be required to be canceled, discontinued, or terminated, because the health benefit plan does not meet the requirements of Title I of the federal Patient Protection and Affordable Care Act (H.R. 3590), as amended by the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152)(the PPACA) or regulations promulgated thereunder, to the extent and under the terms that the appropriate federal authority has suspended enforcement of provisions of Title I of the PPACA or regulations promulgated thereunder. This section applies to health benefit plans sold or offered for sale in the individual and group markets.

2014, Sp. Sess. I, cc. 4, 5; 2016, c. 271; 2020, c. 842.

Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3455. Definitions.
As used in this article, unless the context requires otherwise:

"Exchange" means either a (i) federal health benefit exchange established by the Secretary of the U.S. Department of Health and Human Services pursuant to § 1321 of the Patient Protection and Affordable Care Act codified as 42 U.S.C. § 18041(c) in the Commonwealth or (ii) state-based exchange established pursuant to Chapter 65 (§ 38.2-6500 et seq.) and § 1311 (b) of the Patient Protection and Affordable Care Act codified as 42 U.S.C. § 18031.

"Health carrier" has the same meaning assigned to that term in § 38.2-3438.

"Navigator" means an individual or entity described in 42 U.S.C. § 1311(i)(2) that is selected to perform the activities and duties identified in 42 U.S.C. § 18031 (i) in the Commonwealth. "Navigator" does not include an individual or entity licensed as an agent under Chapter 18 (§ 38.2-1800 et seq.) of this title to sell, solicit, or negotiate contracts of insurance or annuity in the Commonwealth.

"Other affordable care options" means the programs provided under the state plan for medical assistance services pursuant to pursuant to Title XIX of the Social Security Act, as amended, and the Family Access to Medical Insurance Security (FAMIS) Plan developed pursuant to Title XXI of the Social Security Act, as amended.

"Qualified dental plan" means a limited scope dental plan that has in effect a certification that the plan meets the criteria for certification described in § 1311(d)(2)(B)(ii) of the Patient Protection and Affordable Care Act, P.L. 111-148, as amended.

"Qualified health plan" means a health benefit plan that has in effect a certification that the plan meets the criteria for certification described in § 1311(c) of the Patient Protection and Affordable Care Act, P.L. 111-148, as amended.

"Secretary" means the Secretary of the U.S. Department of Health and Human Services.

2013, cc. 595, 791; 2014, cc. 752, 769; 2020, cc. 916, 917.
Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3456. Prohibited activities.
A. A navigator shall not:

1. Engage in any activity that would require an insurance agent license under this title;

2. Offer advice about which qualified health plan or qualified dental plan is better or worse for a particular individual or employer;

3. Act as an intermediary between an employer and an insurer that offers a qualified health plan or qualified dental plan offered through an exchange;

4. Violate any unfair trade practice and privacy requirements in §§ 38.2-502, 38.2-503, 38.2-506, 38.2-509, 38.2-512, 38.2-515, 38.2-612.1, 38.2-613, and 38.2-614 to the extent such requirements are applicable to the activities of navigators; or

5. Receive compensation for services or duties as a navigator that are prohibited by federal law, including compensation from a health carrier.

B. An individual or entity shall not claim to be, or otherwise hold himself or itself out as, a navigator or conduct business as a navigator in the Commonwealth without:

1. Having been selected as a navigator in accordance with applicable federal or state law;

2. Having evidence of successful completion of all navigator requirements prescribed by the Secretary or the Exchange; and

3. Having met requirements established pursuant to § 38.2-3457.

C. If an individual or entity has engaged in the Commonwealth in one or more of the prohibited activities identified in this section, a complaint may be filed with the Commission. The Commission, upon investigation and verification of the prohibited activity or activities, may order such individual or entity to cease and desist such prohibited conduct.

2013, cc. 595, 791; 2014, cc. 752, 769; 2020, cc. 916, 917.

Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3457. Application for registration.
A. On or after September 1, 2014, no individual or entity shall act as a navigator in the Commonwealth unless such individual or entity has been certified by the U.S. Department of Health and Human Services or the Exchange and registered with the Commission.

B. An application for registration under this article shall be in the form and containing the information the Commission prescribes. Each applicant shall, at the time of applying for registration, pay a nonrefundable application processing fee in an amount and in a manner prescribed by the Commission. A criminal history record report shall accompany each individual registration application.

C. The Commission shall register the applicant if it finds that the character and general fitness of the applicant are such as to warrant belief that the applicant will act as a navigator fairly, in the public interest, and in accordance with law.

2014, cc. 752, 769; 2020, cc. 916, 917.
Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3458. Power of Commission to investigate navigators.
A. The Commission shall have the power to examine and investigate the affairs of any person engaged or alleged to be engaged in navigator activities in the Commonwealth to determine whether the individual or entity has engaged or is engaging in any violation of this article.

B. Each registered navigator shall report to the Commission within 30 calendar days the following: (i) any action taken by the U.S. Department of Health and Human Services to decertify the navigator; (ii) upon conviction of a felony, the facts and circumstances surrounding that conviction; and (iii) the disposition of the matter of any administrative action taken against the navigator in another jurisdiction or by another governmental agency in the Commonwealth.

2014, cc. 752, 769.

Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3459. Grounds for termination, placing on probation, revocation, or suspension of registration.
A. If the Commission determines that a registered navigator has violated this article, or any order or regulation adopted thereunder, after notice and opportunity to be heard, the Commission may impose a penalty in accordance with §§ 38.2-218 and 38.2-219 and place on probation, suspend, or revoke any individual's or entity's registration.

B. The registration of any navigator shall terminate immediately when such navigator becomes decertified by the U.S. Department of Health and Human Services or the Exchange, as applicable.

2014, cc. 752, 769; 2020, cc. 916, 917.

Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3460. Sufficiency of federal requirements; additional standards and qualifications for navigators.
The Commission may determine whether the standards and qualifications for navigators provided by 42 U.S.C. § 18031 and any regulations enacted thereunder are sufficient to ensure that navigators can perform the required duties. If the Commission determines that the standards and qualifications are insufficient, the Commission shall adopt regulations establishing additional standards and qualifications to ensure that navigators can perform their required duties.

2014, cc. 752, 769; 2020, cc. 916, 917.
Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3463. Health care price transparency tools.
Beginning with health benefit plans offered or renewed on or after July 1, 2020, each health carrier offering a health benefit plan in the Commonwealth shall comply with the following requirements:

1. A health carrier shall establish an interactive mechanism on its website that enables a covered person to request and obtain from the health carrier the estimated out-of-pocket cost to the covered person for comparable health care services from network providers, as well as quality data for those providers, to the extent available. The interactive mechanism shall allow a covered person seeking information about the cost of a comparable health care service to compare estimated out-of-pocket costs applicable to that covered person's health benefit plan. The out-of-pocket estimate shall provide a good faith estimate of the amount the covered person will be responsible to pay out-of-pocket for a proposed comparable health care service or service that is a medically necessary covered benefit from a health carrier's network provider, including any copayment, deductible, coinsurance, or other out-of-pocket amount for any covered benefit, based on the information available to the health carrier at the time the request is made. A health carrier may contract with a third-party vendor to satisfy the requirements of this subdivision.

2. Nothing in this section shall prohibit a health carrier from imposing cost-sharing requirements disclosed in the covered person's covered benefit plan for unforeseen health care services that arise out of the comparable health care service or for a procedure or service provided to a covered person that was not included in an original estimate provided under subdivision 1.

3. A health carrier shall notify a covered person that an estimate provided under subdivision 1 is an estimate of costs and that the actual amount the covered person will be responsible to pay may vary due to the need for unforeseen services that arise out of the proposed comparable health care service.

2019, cc. 666, 684.

Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3464. Rules and regulations; orders.
The Commission, after notice and opportunity for all interested parties to be heard, may issue any rules and regulations necessary or appropriate for the administration and enforcement of this article.

2019, cc. 666, 684.
Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3467. Prohibited conduct by carriers and pharmacy benefits managers.
A. No carrier on its own or through its contracted pharmacy benefits manager or representative of a pharmacy benefits manager shall:

1. Cause or knowingly permit the use of any advertisement, promotion, solicitation, representation, proposal, or offer that is untrue;

2. Charge a pharmacist or pharmacy a fee related to the adjudication of a claim other than a reasonable fee for an initial claim submission;

3. Reimburse a pharmacy or pharmacist an amount less than the amount that the pharmacy benefits manager reimburses a pharmacy benefits manager affiliate for providing the same pharmacist services, calculated on a per-unit basis using the same generic product identifier or generic code number and reflecting all drug manufacturer's rebates, direct and indirect administrative fees, and costs and any remuneration;

4. Penalize or retaliate against a pharmacist or pharmacy for exercising rights provided pursuant to the provisions of this article;

5. Impose requirements, exclusions, reimbursement terms, or other conditions on a covered entity or contract pharmacy that differ from those applied to entities or pharmacies that are not covered entities or contract pharmacies on the basis that the entity or pharmacy is a covered entity or contract pharmacy or that the entity or pharmacy dispenses 340B-covered drugs. Nothing in this subdivision shall (i) apply to drugs with an annual estimated per-patient cost exceeding $250,000 or (ii) prohibit the identification of a 340B reimbursement request; or

6. Interfere with a covered individual's right to choose a pharmacy or provider, based on the pharmacy or provider's status as a covered entity or contract pharmacy.

B. No carrier, on its own or through its contracted pharmacy benefits manager or representative of a pharmacy benefits manager, shall restrict participation of a pharmacy in a pharmacy network for provider accreditation standards or certification requirements if a pharmacist meets such accreditation standards or certification standards.

C. No carrier, on its own or through its contracted pharmacy benefits manager or representative of a pharmacy benefits manager, shall include any mail order pharmacy or pharmacy benefits manager affiliate in calculating or determining network adequacy under any law or contract in the Commonwealth.

D. No carrier, on its own or through its contracted pharmacy benefits manager or representative of a pharmacy benefits manager, shall conduct spread pricing in the Commonwealth.

E. Each carrier on its own or through its contracted pharmacy benefits manager or representative of a pharmacy benefits manager shall comply with the provisions of this section in addition to complying with the provisions of § 38.2-3407.15:1.

2020, cc. 219, 1288; 2022, c. 319.
Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3469. Enforcement; regulations.
A. The Commission shall enforce this article.

B. Pursuant to the authority granted by § 38.2-223, the Commission may promulgate such rules and regulations as it may deem necessary to implement this article.

2020, cc. 219, 1288.

Code of Virginia — Title 38.2 (Insurance), Chapter 34 (Provisions Relating to Accident and Sickness Insurance)
§ 38.2-3470. Scope of article.
This article shall not apply with respect to claims under (i) an employee welfare benefit plan as defined in section 3 (1) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1002(1), that is self-insured or self-funded; (ii) coverages issued pursuant to Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. (Medicaid); or (iii) prescription drug coverages issued pursuant to Part D of Title XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq. (Medicare Part D).

2020, cc. 219, 1288.
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3500. Form of policy.
A. No individual accident and sickness insurance policy shall be delivered or issued for delivery to any person in this Commonwealth unless:

1. The entire consideration for the policy is expressed in the policy;

2. The time at which the insurance takes effect and terminates is expressed in the policy;

3. The policy insures only one person, except that it may insure eligible family members, originally or by subsequent amendment, upon the application of an adult member of a family who shall be deemed the policyowner;

4. The exceptions and reductions are set forth in the policy and, except those that are set forth in §§ 38.2-3503 through 38.2-3508, are printed with the benefit provisions to which they apply, or under an appropriate caption, but if an exception or reduction specifically applies only to a particular benefit of the policy, a statement of the exception or reduction shall be included with that benefit provision;

5. Each form, including riders and endorsements, is identified by a form number in the lower left-hand corner of the first page of the form;

6. It contains no provision making any portion of the charter, rules, constitution, or bylaws of the insurer a part of the policy unless that portion is set forth in the policy, except in the case of the incorporation of, or reference to, a statement of rates or classification of risks, or short-rate table filed with the Commission; and

7. It contains a statement about the provisions of subsections A and B of § 32.1-325.2 regarding the status of the Department of Medical Assistance Services as the payor of last resort.

B. If any policy is issued by an insurer domiciled in this Commonwealth for delivery to a person residing in another state, and if the insurance supervisory official of the other state advises the Commission that any such policy is not subject to approval or disapproval by such official, the Commission may by ruling require that such policy meet the standards set forth in this chapter.

C. "Eligible family member" means the (i) spouse, (ii) dependent children, without regard to whether such children reside in the same household as the policyowner, (iii) children under a specified age not greater than 19 years, and (iv) any person dependent on the policyowner.

D. The provisions of this section shall not apply in any instance in which the provisions of this section are inconsistent or in conflict with a provision of Article 6 (§ 38.2-3438 et seq.) of Chapter 34.

1952, c. 317, § 38.1-348; 1986, cc. 550, 562; 1993, c. 306; 1994, c. 316; 2011, c. 882.
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3501. Policy forms; powers of Commission.
A. Individual accident and sickness insurance policy forms and the rate manuals showing rules and classification of risks applicable to individual accident and sickness insurance policy forms shall be subject to the provisions of § 38.2-316. The Commission, subject to § 38.2-316, may disapprove or withdraw approval of any such policy form if it finds that the benefits provided in the policy form are or are likely to be unreasonable in relation to the premium charged. If the Commission disapproves a policy form or withdraws approval of a form, an insurer may proceed as indicated in § 38.2-1926.

B. The provisions of this section shall not apply in any instance in which the provisions of this section are inconsistent or in conflict with a provision of Article 6 (§ 38.2-3438 et seq.) of Chapter 34.

1979, c. 726, § 38.1-362.8; 1986, c. 562; 2013, c. 751.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3502. Notice to be printed on policy; return of policy to insurer.
A. Any individual accident and sickness insurance policy delivered or issued for delivery in this Commonwealth shall have printed on it a notice stating substantially:

"THIS POLICY MAY NOT APPLY WHEN YOU HAVE A CLAIM! PLEASE READ! This policy was issued based on the information entered in your application, a copy of which is attached to the policy. If you know of any misstatement in your application, or if any information concerning the medical history of any insured person has been omitted, you should advise the Company immediately regarding the incorrect or omitted information; otherwise, your policy may not be a valid contract.

RIGHT TO RETURN POLICY WITHIN 10 DAYS. If for any reason you are not satisfied with your policy, you may return this policy to the Company within ten days of the date you received it and the premium you paid will be promptly refunded."

B. If a policyowner returns the policy within ten days from the date of receipt, coverage under that policy shall become void from its inception upon the mailing or delivery of the policy to the insurer or its agent.

C. If the first paragraph of the notice required in subsection A of this section is inapplicable or partially inapplicable to a particular form of policy, the insurer may modify or omit the notice with the Commission's approval.

D. Nothing in this section shall prohibit an insurer from extending the right to examine period to more than ten days if the period is stated in the policy.

1966, c. 342, § 38.1-348.4; 1986, c. 562.
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3505. Inapplicable or inconsistent provisions.
If any provision of this article is inapplicable to or inconsistent with the coverage provided by a particular form of policy, the insurer, with the Commission's approval, shall omit or modify the inapplicable or inconsistent provision to make that provision consistent with the coverage provided by the policy.

1952, c. 317, § 38.1-351; 1986, c. 562.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3506. Order of certain policy provisions.
The provisions that are the subject of §§ 38.2-3503 and 38.2-3504, or any corresponding provisions that are used instead of them in accordance with these sections, shall be printed in the consecutive order of the provisions in such sections. However, any such provision may appear as a unit in any part of the policy, with other provisions to which it may be logically related, provided the resulting policy shall not be in whole or in part unintelligible, uncertain, ambiguous, abstruse, or likely to mislead a person to whom the policy is offered, delivered or issued.

1952, c. 317, § 38.1-352; 1986, c. 562.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3507. Third-party ownership.
The word "insured," as used in this article, shall not be construed to prevent a person with a proper insurable interest from applying for and owning a policy covering another person or from being entitled to any indemnities, benefits and rights provided under the policy.

1952, c. 317, § 38.1-353; 1986, c. 562.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3508. Requirements of other jurisdictions.
A. Any individual accident and sickness insurance policy delivered or issued for delivery to any person in this Commonwealth by a foreign or alien insurer may contain any provision that is prescribed or required by the insurer's domiciliary jurisdiction and that is not less favorable than the provisions of this article to the insured or the beneficiary.

B. Any individual accident and sickness insurance policy delivered or issued for delivery by a domestic insurer in any other jurisdiction may contain any provision permitted or required by the laws of the other jurisdiction.

Code 1950, § 38-224; 1952, c. 317, § 38.1-354; 1986, c. 562.
Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3509. Denial or reduction of benefits because of existence of other like insurance.
A. No individual accident and sickness insurance policy, nor any subscription contract as provided for in Chapter 42 (§ 38.2-4200 et seq.) of this title, delivered or issued for delivery in this Commonwealth shall contain any provision for the denial or reduction of benefits because of the existence of other like insurance except to the extent that the aggregate benefits, with respect to the covered medical expenses incurred under the policy or plan and all other like insurance with other insurers, exceed all covered medical expenses incurred.

B. The term "other like insurance" may include group insurance or coverage provided by hospital or medical service organizations, union welfare plans, employer or employee benefit organizations, or workers' compensation insurance.

1970, c. 378, § 38.1-355; 1986, c. 562.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3510. Conforming to statute.
No individual accident and sickness insurance policy provision that is not subject to this article shall make an individual accident and sickness insurance policy, or any portion of the policy, less favorable in any respect to the insured or the beneficiary than the provisions that are subject to this article.

Code 1950, § 38-223; 1952, c. 317, § 38.1-356; 1986, c. 562.

Code of Virginia — Title 38.2 (Insurance), Chapter 35 (ACCIDENT AND SICKNESS INSURANCE POLICIES)
§ 38.2-3511. Application.
A. The insured shall not be bound by any statement made in an application for an individual accident and sickness policy unless a copy of the application is attached to or endorsed on the policy when issued as a part of the policy. If any such policy delivered or issued for delivery in this Commonwealth is reinstated or renewed, and the insured, beneficiary or assignee of the policy makes a written request to the insurer for a copy of the reinstatement or renewal application, if any, the insurer shall within fifteen days after the receipt of the request, deliver or mail to the person making the request, a copy of the application. If a copy is not so delivered or mailed, the insurer shall be precluded from introducing the application as evidence in any action or proceeding based upon or involving the policy or its reinstatement or renewal.

B. No alteration of any written application for any such policy shall be made by any person other than the applicant without his written consent, except that insertions may be made by the insurer, for administrative purposes only, in a manner indicating clearly that such insertions are not to be ascribed to the applicant.

C. The falsity of any statement in the application for any policy covered by this article may not bar the right to recovery under the policy unless the false statement materially affected either the acceptance of the risk or the hazard assumed by the insurer.

1952, c. 317, § 38.1-357; 1986, c. 562.