Source: https://vacode.org/2.2-2818/
Timestamp: 2020-07-09 23:36:46
Document Index: 270228384

Matched Legal Cases: ['§ 2', '§ 2', '§ 32', '§ 1471', '§ 1861', '§ 51', '§ 51', '§ 51', '§ 23', '§ 51', '§ 51', '§ 51', '§ 23', '§ 51', '§ 51', '§ 51', '§ 23', '§ 4', '§ 223', '§ 2', '§ 2', '§ 2', '§ 2', '§ 2', '§ 2', '§ 2', '§ 2', '§ 2', '§ 23', '§ 28', '§ 38', '§ 51', '§ 51', '§ 62']

Health and related insurance for state employees (§ 2.2-2818)—Virginia Decoded - Virginia Decoded
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§ 2.2-2818 Health and related insurance for state employees
Health and related insurance for state employees
A. The Department of Human Resource Management shall establish a plan, subject to the approval of the Governor, for providing health insurance coverage, including chiropractic treatment, hospitalization, medical, surgical and major medical coverage, for state employees and retired state employees with the Commonwealth paying the cost thereof to the extent of the coverage included in such plan. The same plan shall be offered to all part-time state employees, but the total cost shall be paid by such part-time employees. The Department of Human Resource Management shall administer this section. The plan chosen shall provide means whereby coverage for the families or dependents of state employees may be purchased. Except for part-time employees, the Commonwealth may pay all or a portion of the cost thereof, and for such portion as the Commonwealth does not pay, the employee, including a part-time employee, may purchase the coverage by paying the additional cost over the cost of coverage for an employee.Such contribution shall be financed through appropriations provided by law.
1. Include coverage for low-dose screening mammograms for determining the presence of occult breast cancer. Such coverage shall make available one screening mammogram to persons age 35 through 39, one such mammogram biennially to persons age 40 through 49, and one such mammogram annually to persons age 50 and over and may be limited to a benefit of $ 50 per mammogram subject to such dollar limits, deductibles, and coinsurance factors as are no less favorable than for physical illness generally.The term “mammogram” shall mean an X-ray examination of the breast using equipment dedicated specifically for mammography, including but not limited to the X-ray tube, filter, compression device, screens, film, and cassettes, with an average radiation exposure of less than one rad mid-breast, two views of each breast.In order to be considered a screening mammogram for which coverage shall be made available under this section:
2. Include coverage for postpartum services providing inpatient care and a home visit or visits that shall be in accordance with the medical criteria, outlined in the most current version of or an official update to the “Guidelines for Perinatal Care” prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists or the “Standards for Obstetric-Gynecologic Services” prepared by the American College of Obstetricians and Gynecologists. Such coverage shall be provided incorporating any changes in such Guidelines or Standards within six months of the publication of such Guidelines or Standards or any official amendment thereto.
3. Include an appeals process for resolution of complaints that shall provide reasonable procedures for the resolution of such complaints and shall be published and disseminated to all covered state employees. The appeals process shall be compliant with federal rules and regulations governing nonfederal, self-insured governmental health plans. The appeals process shall include a separate expedited emergency appeals procedure that shall provide resolution within time frames established by federal law. For appeals involving adverse decisions as defined in § 32.1-137.7, the Department shall contract with one or more independent review organizations to review such decisions. Independent review organizations are entities that conduct independent external review of adverse benefit determinations. The Department shall adopt regulations to assure that the independent review organization conducting the reviews has adequate standards, credentials and experience for such review. The independent review organization shall examine the final denial of claims to determine whether the decision is objective, clinically valid, and compatible with established principles of health care. The decision of the independent review organization shall (i) be in writing, (ii) contain findings of fact as to the material issues in the case and the basis for those findings, and (iii) be final and binding if consistent with law and policy.Prior to assigning an appeal to an independent review organization, the Department shall verify that the independent review organization conducting the review of a denial of claims has no relationship or association with (i) the covered person or the covered person’s authorized representative; (ii) the treating health care provider, or any of its employees or affiliates; (iii) the medical care facility at which the covered service would be provided, or any of its employees or affiliates; or (iv) the development or manufacture of the drug, device, procedure or other therapy that is the subject of the final denial of a claim. The independent review organization shall not be a subsidiary of, nor owned or controlled by, a health plan, a trade association of health plans, or a professional association of health care providers. There shall be no liability on the part of and no cause of action shall arise against any officer or employee of an independent review organization for any actions taken or not taken or statements made by such officer or employee in good faith in the performance of his powers and duties.
4. Include coverage for early intervention services. For purposes of this section, “early intervention services” means medically necessary speech and language therapy, occupational therapy, physical therapy and assistive technology services and devices for dependents from birth to age three who are certified by the Department of Behavioral Health and Developmental Services as eligible for services under Part H of the Individuals with Disabilities Education Act (20 U.S.C. § 1471 et seq.). Medically necessary early intervention services for the population certified by the Department of Behavioral Health and Developmental Services shall mean those services designed to help an individual attain or retain the capability to function age-appropriately within his environment, and shall include services that enhance functional ability without effecting a cure.For persons previously covered under the plan, there shall be no denial of coverage due to the existence of a preexisting condition. The cost of early intervention services shall not be applied to any contractual provision limiting the total amount of coverage paid by the insurer to or on behalf of the insured during the insured’s lifetime.
8. Include coverage for equipment, supplies and outpatient self-management training and education, including medical nutrition therapy, for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes and noninsulin-using diabetes if prescribed by a health care professional legally authorized to prescribe such items under law. To qualify for coverage under this subdivision, diabetes outpatient self-management training and education shall be provided by a certified, registered or licensed health care professional.
9. Include coverage for reconstructive breast surgery. For purposes of this section, “reconstructive breast surgery” means surgery performed on and after July 1, 1998, (i) coincident with a mastectomy performed for breast cancer or (ii) following a mastectomy performed for breast cancer to reestablish symmetry between the two breasts. For persons previously covered under the plan, there shall be no denial of coverage due to preexisting conditions.
12. Include coverage (i) to persons age 50 and over and (ii) to persons age 40 and over who are at high risk for prostate cancer, according to the most recent published guidelines of the American Cancer Society, for one PSA test in a 12-month period and digital rectal examinations, all in accordance with American Cancer Society guidelines. For the purpose of this subdivision, “PSA testing” means the analysis of a blood sample to determine the level of prostate specific antigen.
13. Permit any individual covered under the plan direct access to the health care services of a participating specialist (i) authorized to provide services under the plan and (ii) selected by the covered individual. The plan shall have a procedure by which an individual who has an ongoing special condition may, after consultation with the primary care physician, receive a referral to a specialist for such condition who shall be responsible for and capable of providing and coordinating the individual’s primary and specialty care related to the initial specialty care referral. If such an individual’s care would most appropriately be coordinated by such a specialist, the plan shall refer the individual to a specialist. For the purposes of this subdivision, “special condition” means a condition or disease that is (i) life-threatening, degenerative, or disabling and (ii) requires specialized medical care over a prolonged period of time. Within the treatment period authorized by the referral, such specialist shall be permitted to treat the individual without a further referral from the individual’s primary care provider and may authorize such referrals, procedures, tests, and other medical services related to the initial referral as the individual’s primary care provider would otherwise be permitted to provide or authorize. The plan shall have a procedure by which an individual who has an ongoing special condition that requires ongoing care from a specialist may receive a standing referral to such specialist for the treatment of the special condition. If the primary care provider, in consultation with the plan and the specialist, if any, determines that such a standing referral is appropriate, the plan or issuer shall make such a referral to a specialist. Nothing contained herein shall prohibit the plan from requiring a participating specialist to provide written notification to the covered individual’s primary care physician of any visit to such specialist. Such notification may include a description of the health care services rendered at the time of the visit.
14. Include provisions allowing employees to continue receiving health care services for a period of up to 90 days from the date of the primary care physician’s notice of termination from any of the plan’s provider panels. The plan shall notify any provider at least 90 days prior to the date of termination of the provider, except when the provider is terminated for cause.For a period of at least 90 days from the date of the notice of a provider’s termination from any of the plan’s provider panels, except when a provider is terminated for cause, a provider shall be permitted by the plan to render health care services to any of the covered employees who (i) were in an active course of treatment from the provider prior to the notice of termination and (ii) request to continue receiving health care services from the provider.Notwithstanding the provisions of this subdivision, any provider shall be permitted by the plan to continue rendering health services to any covered employee who has entered the second trimester of pregnancy at the time of the provider’s termination of participation, except when a provider is terminated for cause. Such treatment shall, at the covered employee’s option, continue through the provision of postpartum care directly related to the delivery.Notwithstanding the provisions of this subdivision, any provider shall be permitted to continue rendering health services to any covered employee who is determined to be terminally ill (as defined under § 1861(dd)(3)(A) of the Social Security Act) at the time of a provider’s termination of participation, except when a provider is terminated for cause. Such treatment shall, at the covered employee’s option, continue for the remainder of the employee’s life for care directly related to the treatment of the terminal illness.A provider who continues to render health care services pursuant to this subdivision shall be reimbursed in accordance with the carrier’s agreement with such provider existing immediately before the provider’s termination of participation.
15. Include coverage for patient costs incurred during participation in clinical trials for treatment studies on cancer, including ovarian cancer trials.The reimbursement for patient costs incurred during participation in clinical trials for treatment studies on cancer shall be determined in the same manner as reimbursement is determined for other medical and surgical procedures. Such coverage shall have durational limits, dollar limits, deductibles, copayments and coinsurance factors that are no less favorable than for physical illness generally.For purposes of this subdivision:”Cooperative group” means a formal network of facilities that collaborate on research projects and have an established NIH-approved peer review program operating within the group. “Cooperative group” includes (i) the National Cancer Institute Clinical Cooperative Group and (ii) the National Cancer Institute Community Clinical Oncology Program.”FDA” means the Federal Food and Drug Administration.”Multiple project assurance contract” means a contract between an institution and the federal Department of Health and Human Services that defines the relationship of the institution to the federal Department of Health and Human Services and sets out the responsibilities of the institution and the procedures that will be used by the institution to protect human subjects.”NCI” means the National Cancer Institute.”NIH” means the National Institutes of Health.”Patient” means a person covered under the plan established pursuant to this section.”Patient cost” means the cost of a medically necessary health care service that is incurred as a result of the treatment being provided to a patient for purposes of a clinical trial. “Patient cost” does not include (i) the cost of nonhealth care services that a patient may be required to receive as a result of the treatment being provided for purposes of a clinical trial, (ii) costs associated with managing the research associated with the clinical trial, or (iii) the cost of the investigational drug or device.Coverage for patient costs incurred during clinical trials for treatment studies on cancer shall be provided if the treatment is being conducted in a Phase II, Phase III, or Phase IV clinical trial. Such treatment may, however, be provided on a case-by-case basis if the treatment is being provided in a Phase I clinical trial.The treatment described in the previous paragraph shall be provided by a clinical trial approved by:
e. An institutional review board of an institution in the Commonwealth that has a multiple project assurance contract approved by the Office of Protection from Research Risks of the NCI.The facility and personnel providing the treatment shall be capable of doing so by virtue of their experience, training, and expertise.Coverage under this subdivision shall apply only if:
(1. There is no clearly superior, noninvestigational treatment alternative;
(2. The available clinical or preclinical data provide a reasonable expectation that the treatment will be at least as effective as the noninvestigational alternative; and
(3. The patient and the physician or health care provider who provides services to the patient under the plan conclude that the patient’s participation in the clinical trial would be appropriate, pursuant to procedures established by the plan.
16. Include coverage providing a minimum stay in the hospital of not less than 23 hours for a covered employee following a laparoscopy-assisted vaginal hysterectomy and 48 hours for a covered employee following a vaginal hysterectomy, as outlined in Milliman & Robertson’s nationally recognized guidelines. Nothing in this subdivision shall be construed as requiring the provision of the total hours referenced when the attending physician, in consultation with the covered employee, determines that a shorter hospital stay is appropriate.
17. Include coverage for biologically based mental illness.For purposes of this subdivision, a “biologically based mental illness” is any mental or nervous condition caused by a biological disorder of the brain that results in a clinically significant syndrome that substantially limits the person’s functioning; specifically, the following diagnoses are defined as biologically based mental illness as they apply to adults and children: schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, panic disorder, obsessive-compulsive disorder, attention deficit hyperactivity disorder, autism, and drug and alcoholism addiction.Coverage for biologically based mental illnesses shall neither be different nor separate from coverage for any other illness, condition or disorder for purposes of determining deductibles, benefit year or lifetime durational limits, benefit year or lifetime dollar limits, lifetime episodes or treatment limits, copayment and coinsurance factors, and benefit year maximum for deductibles and copayment and coinsurance factors.Nothing shall preclude the undertaking of usual and customary procedures to determine the appropriateness of, and medical necessity for, treatment of biologically based mental illnesses under this option, provided that all such appropriateness and medical necessity determinations are made in the same manner as those determinations made for the treatment of any other illness, condition or disorder covered by such policy or contract.
18. Offer and make available coverage for the treatment of morbid obesity through gastric bypass surgery or such other methods as may be recognized by the National Institutes of Health as effective for the long-term reversal of morbid obesity. Such coverage shall have durational limits, dollar limits, deductibles, copayments and coinsurance factors that are no less favorable than for physical illness generally. Access to surgery for morbid obesity shall not be restricted based upon dietary or any other criteria not approved by the National Institutes of Health. For purposes of this subdivision, “morbid obesity” means (i) a weight that is at least 100 pounds over or twice the ideal weight for frame, age, height, and gender as specified in the 1983 Metropolitan Life Insurance tables, (ii) a body mass index (BMI) equal to or greater than 35 kilograms per meter squared with comorbidity or coexisting medical conditions such as hypertension, cardiopulmonary conditions, sleep apnea, or diabetes, or (iii) a BMI of 40 kilograms per meter squared without such comorbidity. As used herein, “BMI” equals weight in kilograms divided by height in meters squared.
D. For the purposes of this section:”Peer-reviewed medical literature” means a scientific study published only after having been critically reviewed for scientific accuracy, validity, and reliability by unbiased independent experts in a journal that has been determined by the International Committee of Medical Journal Editors to have met the Uniform Requirements for Manuscripts submitted to biomedical journals. Peer-reviewed medical literature does not include publications or supplements to publications that are sponsored to a significant extent by a pharmaceutical manufacturing company or health carrier.”Standard reference compendia” means:
1. American Hospital Formulary Service — Drug Information;
3. Elsevier Gold Standard’s Clinical Pharmacology. (Effective until October 1, 2016)”State employee” means state employee as defined in § 51.1-124.3; employee as defined in § 51.1-201; the Governor, Lieutenant Governor and Attorney General; judge as defined in § 51.1-301 and judges, clerks and deputy clerks of regional juvenile and domestic relations, county juvenile and domestic relations, and district courts of the Commonwealth; and interns and residents employed by the School of Medicine and Hospital of the University of Virginia, and interns, residents, and employees of the Virginia Commonwealth University Health System Authority as provided in § 23-50.16:24. (Effective October 1, 2016, until July 1, 2018)”State employee” means state employee as defined in § 51.1-124.3; employee as defined in § 51.1-201; the Governor, Lieutenant Governor and Attorney General; judge as defined in § 51.1-301 and judges, clerks and deputy clerks of regional juvenile and domestic relations, county juvenile and domestic relations, and district courts of the Commonwealth; and interns and residents employed by the School of Medicine and Hospital of the University of Virginia, and interns, residents, and employees of the Virginia Commonwealth University Health System Authority as provided in § 23.1-2415. (Effective July 1, 2018)”State employee” means state employee as defined in § 51.1-124.3; employee as defined in § 51.1-201; the Governor, Lieutenant Governor and Attorney General; judge as defined in § 51.1-301 and judges, clerks and deputy clerks of regional juvenile and domestic relations, county juvenile and domestic relations, and district courts of the Commonwealth; interns and residents employed by the School of Medicine and Hospital of the University of Virginia, and interns, residents, and employees of the Virginia Commonwealth University Health System Authority as provided in § 23.1-2415; and employees of the Virginia Alcoholic Beverage Control Authority as provided in § 4.1-101.05.
G. The plan shall include, in each planning district, at least two health coverage options, each sponsored by unrelated entities. No later than July 1, 2006, one of the health coverage options to be available in each planning district shall be a high deductible health plan that would qualify for a health savings account pursuant to § 223 of the Internal Revenue Code of 1986, as amended.In each planning district that does not have an available health coverage alternative, the Department shall voluntarily enter into negotiations at any time with any health coverage provider who seeks to provide coverage under the plan.This subsection shall not apply to any state agency authorized by the Department to establish and administer its own health insurance coverage plan separate from the plan established by the Department.
H. Any self-insured group health insurance plan established by the Department of Human Resource Management that includes coverage for prescription drugs on an outpatient basis may apply a formulary to the prescription drug benefits provided by the plan if the formulary is developed, reviewed at least annually, and updated as necessary in consultation with and with the approval of a pharmacy and therapeutics committee, a majority of whose members are actively practicing licensed (i) pharmacists, (ii) physicians, and (iii) other health care providers.If the plan maintains one or more drug formularies, the plan shall establish a process to allow a person to obtain, without additional cost-sharing beyond that provided for formulary prescription drugs in the plan, a specific, medically necessary nonformulary prescription drug if, after reasonable investigation and consultation with the prescriber, the formulary drug is determined to be an inappropriate therapy for the medical condition of the person. The plan shall act on such requests within one business day of receipt of the request.Any plan established in accordance with this section shall be authorized to provide for the selection of a single mail order pharmacy provider as the exclusive provider of pharmacy services that are delivered to the covered person’s address by mail, common carrier, or delivery service. As used in this subsection, “mail order pharmacy provider” means a pharmacy permitted to conduct business in the Commonwealth whose primary business is to dispense a prescription drug or device under a prescriptive drug order and to deliver the drug or device to a patient primarily by mail, common carrier, or delivery service.
L. The Department of Human Resource Management shall appoint an Ombudsman to promote and protect the interests of covered employees under any state employee’s health plan.The Ombudsman shall:
M. The plan established in accordance with this section shall not refuse to accept or make reimbursement pursuant to an assignment of benefits made to a dentist or oral surgeon by a covered employee.For purposes of this subsection, “assignment of benefits” means the transfer of dental care coverage reimbursement benefits or other rights under the plan. The assignment of benefits shall not be effective until the covered employee notifies the plan in writing of the assignment.
N. Beginning July 1, 2006, any plan established pursuant to this section shall provide for an identification number, which shall be assigned to the covered employee and shall not be the same as the employee’s social security number.
O. Any group health insurance plan established by the Department of Human Resource Management that contains a coordination of benefits provision shall provide written notification to any eligible employee as a prominent part of its enrollment materials that if such eligible employee is covered under another group accident and sickness insurance policy, group accident and sickness subscription contract, or group health care plan for health care services, that insurance policy, subscription contract or health care plan may have primary responsibility for the covered expenses of other family members enrolled with the eligible employee. Such written notification shall describe generally the conditions upon which the other coverage would be primary for dependent children enrolled under the eligible employee’s coverage and the method by which the eligible enrollee may verify from the plan that coverage would have primary responsibility for the covered expenses of each family member.
P. Any plan established by the Department of Human Resource Management pursuant to this section shall provide that coverage under such plan for family members enrolled under a participating state employee’s coverage shall continue for a period of at least 30 days following the death of such state employee.
1970, c. 557, § 2.1-20.1; 1972, c. 803; 1973, cc. 69, 297; 1978, c. 70; 1984, c. 430; 1988, c. 634; 1989, cc. 559, 664; 1990, c. 607; 1993, c. 138; 1995, c. 353; 1996, cc. 155, 201, 905, 1046; 1997, cc. 43, 468, 521, 656; 1998, cc. 35, 56, 257, 386, 631, 709, 851, 858, 875; 1999, cc. 643, 649, 921, 941; 2000, cc. 66, 149, 465, 534, 657, 720, 888; 2001, cc. 334, 558, 663, 844; 2004, cc. 156, 279, 855; 2005, cc. 503, 572, 640, 739; 2006, c. 396; 2008, c. 420; 2009, cc. 247, 317, 813, 840; 2010, cc. 157, 357, 443; 2012, cc. 60, 201; 2013, c. 709; 2014, c. 631; 2015, cc. 38, 730.
If you’re reading this for anything important, you should double-check its accuracy—read § 2.2-2818 on the official Code of Virginia website.
HB300: Physician assistants; provides that they may sign various forms and certificates, etc.
HB946: Health insurance; assignment of benefits to emergency care physicians.
HB2651: State employees; removes reference to Milliman & Robertson's guidelines from Code. (failed)
HB2948: State employees; health insurance plan to provide coverage for radiation therapy. (failed)
HB946: Health insurance; assignment of benefits to emergency care physicians. (failed)
HB1190: Infant mortality; requires certain measures designed to lower. (failed)
HB1419: Health insurance; coordination of benefits. (failed)
SB785: Health insurance; repeals provision requiring coverage for bone marrow transplants. (passed)
HB1977: Health insurance; mandated coverage for prosthetic devices and components. (failed)
HB2557: Health insurance plan, State; coverages and benefits. (passed)
SB1260: Health insurance; mandated coverage for autism spectrum disorder. (failed)
SB1351: Health insurance plan; insurance mandate for accident, etc. apply to plans for state employees. (passed)
SB645: Health insurance; mandated coverage for prosthetic devices and components. (failed)
SB535: Mail order pharmacy; insurer not limited to a single provider for services. (passed)
SB1061: State employee health insurance plan; coverage for autism spectrum disorder. (failed)
SB1122: State employees; health insurance benefits. (failed)
HB357: Virginia Health Benefit Exchange Authority; created. (failed)
HB715: Health plan, State; makes changes to appeals process for complaints. (passed)
SB499: Health plan, state; makes changes to appeals process for complaints. (passed)
HB2138: Health Insurance Reform Commission; established, sunset provision, report. (passed)
HB463: State health plan; participation by employees of local school divisions. (failed)
SB252: Insurance; state health care plan to provide that coverage of 1 additional adult may be purchased. (failed)
SB464: Human Resource Management, Department of; state health plan. (passed)
SB1262: Health insurance; carrier business practices. (passed)
HB1215: Health insurance; programs for local employees. (failed)
HB848: Health insurance; programs for local government employees. (failed)
SB675: Health insurance for local employees. (failed)
HB1872: State employee health insurance plan; coverage for vision therapy. (failed)
HB1267: State employee health plan; coverage for gender transition services. (failed)
HB332: State employee health insurance plan; coverage for proton therapy. (failed)
HB1087: High deductible health plans; funding deductibles through health savings accounts. (failed)
§ 2.2-1204 Health insurance program for employees of local governments, local officers, teachers, etc.; definitions
§ 2.2-2203.3 Employees; employment; personnel rules
§ 2.2-2818.01 Employer contributions
§ 2.2-2818.1 Supplemental health insurance coverage; state employees eligible for military health insurance coverage
§ 2.2-2818.2 Application of mandates to the state employee health insurance plan
§ 2.2-2820 Purchase of health insurance coverage by part-time state employees
§ 2.2-3203 Transitional severance benefit conferred
§ 23.1-2415 (Effective October 1, 2016) Employees of the Authority
§ 28.2-1001 Potomac River Compact
§ 38.2-3424.1 Applicability
§ 51.1-1400 Health insurance credits for retired state employees
§ 51.1-1405 Participation in the state retiree health benefits program
§ 62.1-129.1 Employees; employment; personnel rules; health insurance; retirement plans