reglab/statecodes huggingface dataset:
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 170 - RULES GOVERNING MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 14VAC5-170-105 - Guaranteed issue for eligible persons

Current through Register Vol. 40, No. 24, July 15, 2024
A. Guaranteed issue provisions follow:
1. Eligible persons are those individuals
				described in subsection B of this section who seek to enroll under the policy
				during the period specified in subsection C of this section, and who submit
				evidence of the date of termination, disenrollment, or Medicare Part D
				enrollment with the application for a Medicare supplement policy.
2. With respect to eligible persons, an
				issuer shall not deny or condition the issuance or effectiveness of a Medicare
				supplement policy described in subsection E of this section that is offered and
				is available for issuance to new enrollees by the issuer, shall not
				discriminate in the pricing of such a Medicare supplement policy because of
				health status, claims experience, receipt of health care or medical condition,
				and shall not impose an exclusion of benefits based on a preexisting condition
				under such a Medicare supplement policy.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 170 - RULES GOVERNING MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 14VAC5-170-110 - Standards for claims payment

Current through Register Vol. 40, No. 24, July 15, 2024
A. An issuer shall comply with §
				1882(c)(3) of the Social Security Act (as enacted by § 4081(b)(2)(C) of
				the Omnibus Budget Reconciliation Act of 1987 (OBRA) 1987, Public Law No.
				100-203, 101 Stat. 1330 (December 22, 1991)) by:
1. Accepting a notice from a Medicare carrier
				on dually assigned claims submitted by participating physicians and suppliers
				as a claim for benefits in place of any other claim form otherwise required and
				making a payment determination on the basis of the information contained in
				that notice;
2. Notifying the
				participating physician or supplier and the beneficiary of the payment
				determination;
3. Paying the
				participating physician or supplier directly;
4. Furnishing, at the time of enrollment,
				each enrollee with a card listing the policy name, number, and a central
				mailing address to which notices from a Medicare carrier may be sent;
5. Paying user fees for claim notices that
				are transmitted electronically or otherwise; and
6. Providing to the Secretary, at least
				annually, a central mailing address to which all claims may be sent by Medicare
				carriers.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 170 - RULES GOVERNING MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 14VAC5-170-120 - Loss ratio standards and refund or credit of premium; annual filing; public hearing

Current through Register Vol. 40, No. 24, July 15, 2024
A.
1. Loss ratio standards. A Medicare
				supplement policy form or certificate form shall not be delivered or issued for
				delivery unless the policy form or certificate form can be expected, as
				estimated for the entire period for which rates are computed to provide
				coverage, to return to policyholders and certificateholders in the form of
				aggregate benefits (not including anticipated refunds or credits) provided
				under the policy form or certificate form:
a.
				At least 75% of the aggregate amount of premiums earned in the case of group
				policies; or
b. At least 65% of the
				aggregate amount of premiums earned in the case of individual policies,
				calculated on the basis of incurred claims experience or incurred health care
				expenses where coverage is provided by a health maintenance organization on a
				service rather than reimbursement basis and earned premiums for such period and
				in accordance with accepted actuarial principles and practices. Incurred health
				care expenses where coverage is provided by a health maintenance organization
				shall not include:
(1) Home office and
				overhead costs;
(2) Advertising
				costs;
(3) Commissions and other
				acquisition costs;
(4)
				Taxes;
(5) Capital costs;
(6) Administrative costs; and
(7) Claims processing costs.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 170 - RULES GOVERNING MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 14VAC5-170-130 - Filing and approval of policies and certificates and premium rates

Current through Register Vol. 40, No. 24, July 15, 2024
A. An issuer shall not deliver or issue for delivery a policy or certificate to a resident of this Commonwealth unless the policy form or certificate form has been filed with and approved by the State Corporation Commission in accordance with filing requirements and procedures prescribed by the State Corporation Commission.
In addition, no rider, endorsement, or amendment, including any rider, endorsement, or amendment designed to delete outpatient prescription drug benefits as required by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (42 USC §
											1395w-101), shall be attached to or printed or stamped upon a policy or certificate form delivered or issued for delivery in this Commonwealth unless the form of the rider, endorsement, or amendment has been filed with and approved by the State Corporation Commission.
B. An issuer shall not use or change premium rates for a Medicare supplement policy or certificate unless the rates, rating schedule, and supporting documentation have been filed with and approved by the State Corporation Commission in accordance with the filing requirements and procedures prescribed by the State Corporation Commission.
The filing shall also include a certification by a qualified actuary that to the best of the actuary's knowledge and judgment, the following items are true with respect to the filing:
1. The assumptions present the actuary's best judgment as to the reasonable value for each assumption and are consistent with the issuer's business plan at the time of the filing;
2. The anticipated lifetime loss ratio, future loss ratios, and except for policies issued prior to July 30, 1992, third-year loss ratio all exceed the applicable ratio;
3. The filing was prepared based on the current standards or practices as promulgated by the Actuarial Standards Board including the data quality standard of practice as described at
www.actuary.org
;
4. The filing is in compliance with applicable laws and regulations in this Commonwealth; and
5. The premiums are reasonable in relation to the benefits provided.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 170 - RULES GOVERNING MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 14VAC5-170-140 - Permitted compensation arrangements

Current through Register Vol. 40, No. 24, July 15, 2024
A. An issuer or other entity may provide
				commission or other compensation to an agent or other representative for the
				sale of a Medicare supplement policy or certificate only if the first year
				commission or other first year compensation is no more than 200% of the
				commission or other compensation paid for selling or servicing the policy or
				certificate in the second year or period.
B. The commission or other compensation
				provided in subsequent (renewal) years must be the same as that provided in the
				second year or period and must be provided for no fewer than five renewal
				years.
C. No issuer or other entity
				shall provide compensation to its agents or other producers and no agent or
				producer shall receive compensation greater than the renewal compensation
				payable by the replacing issuer on renewal policies or certificates if an
				existing policy or certificate is replaced.
D. For purposes of this section,
				"compensation" includes pecuniary or nonpecuniary remuneration of any kind
				relating to the sale or renewal of the policy or certificate including, but not
				limited to, bonuses, gifts, prizes, awards, and finders' fees.
Statutory Authority
§§ 12.1-13 and 38.2-223 of the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 170 - RULES GOVERNING MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 14VAC5-170-170 - Filing requirements for advertising

Current through Register Vol. 40, No. 24, July 15, 2024
An issuer shall provide a copy of any Medicare supplement
				  advertisement intended for use in this Commonwealth whether through written,
				  radio or television medium to the State Corporation Commission for
				  review.
Statutory Authority
§§ 12.1-13 and 38.2-223 of the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 170 - RULES GOVERNING MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 14VAC5-170-180 - Standards for marketing

Current through Register Vol. 40, No. 24, July 15, 2024
A. An
				issuer, directly or through its producers, shall:
1. Establish marketing procedures to assure
				that any comparison of policies by its agents or other producers will be fair
				and accurate.
2. Establish
				marketing procedures to assure excessive insurance is not sold or
				issued.
3. Display prominently by
				type, stamp or other appropriate means, on the first page of the policy the
				following:
"Notice to buyer: This policy may not cover all of your
				  medical expenses."
4.
				Inquire and otherwise make every reasonable effort to identify whether a
				prospective applicant or enrollee for Medicare supplement insurance already has
				accident and sickness insurance and the types and amounts of any such
				insurance.
5. If the Medicare
				supplement policy or certificate uses attained age rating, all marketing
				materials or rate quotations other than the outline of coverage shall display
				prominently the following notice in close proximity to anywhere the insurer or
				agent displays a premium:
"Notice: This (policy's/certificate's) premium increases
				  based on your attained age. Please read the Notice For Attained Age Rated
				  Medicare Supplement Policies carefully. It is available upon request or at the
				  time the application is presented."
6. Establish auditable procedures for
				verifying compliance with subsection A of this section.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 170 - RULES GOVERNING MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 14VAC5-170-190 - Appropriateness of recommended purchase and excessive insurance

Current through Register Vol. 40, No. 24, July 15, 2024
A. In recommending
				the purchase or replacement of any Medicare supplement policy or certificate an
				agent shall make reasonable efforts to determine the appropriateness of a
				recommended purchase or replacement.
B. Any sale of a Medicare supplement policy
				or certificate that will provide an individual more than one Medicare
				supplement policy or certificate is prohibited.
C. An issuer shall not issue a Medicare
				supplement policy or certificate to an individual enrolled in Medicare Part C
				unless the effective date of the coverage is after the termination date of the
				individual's Part C coverage.
Statutory Authority
§§ 12.1-13 and 38.2-223 of the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 170 - RULES GOVERNING MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 14VAC5-170-200 - Reporting of multiple policies

Current through Register Vol. 40, No. 24, July 15, 2024
A. On or before March 1 of each year, an
				issuer shall report in the format prescribed in Appendix B the following
				information for every individual resident of this Commonwealth for which the
				issuer has in force more than one Medicare supplement policy or certificate:
1. Policy and certificate number,
				and
2. Date of issuance.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 170 - RULES GOVERNING MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 14VAC5-170-210 - Prohibition against preexisting conditions, waiting periods, elimination periods and probationary periods in replacement policies or certificates

Current through Register Vol. 40, No. 24, July 15, 2024
A. If a Medicare
				supplement policy or certificate replaces another Medicare supplement policy or
				certificate, the replacing issuer shall waive any time periods applicable to
				preexisting conditions, waiting periods, elimination periods and probationary
				periods in the new Medicare supplement policy or certificate to the extent such
				time was spent under the original policy.
B. If a Medicare supplement policy or
				certificate replaces another Medicare supplement policy or certificate which
				has been in effect for at least six months, the replacing policy shall not
				provide any time period applicable to preexisting conditions, waiting periods,
				elimination periods and probationary periods.
Statutory Authority
§§ 38.2-223, 38.2-514, 38.2-3516 through
					 38.2-3520, 38.2-3600 through 38.2-3609, 38.2-4214, and 38.2-4215 of the Code of
					 Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 170 - RULES GOVERNING MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 14VAC5-170-215 - Prohibition against use of genetic information and requests for genetic testing

Current through Register Vol. 40, No. 24, July 15, 2024
A. An
				issuer of a Medicare supplement policy or certificate:
1. Shall not deny or condition the issuance
				or effectiveness of the policy or certificate (including the imposition of any
				exclusion of benefits under the policy based on a preexisting condition) on the
				basis of the genetic information with respect to such individual; and
2. Shall not discriminate in the pricing of
				the policy or certificate (including the adjustment of premium rates) of an
				individual on the basis of the genetic information with respect to such
				individual.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 170 - RULES GOVERNING MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 14VAC5-170-220 - Severability

Current through Register Vol. 40, No. 24, July 15, 2024
If any provision of this chapter (14VAC5-170-10 et seq.), or the
				  application thereof to any person or circumstance is for any reason held to be
				  invalid, the remainder of the regulation and the application of such provision
				  to other persons or circumstances shall not be affected
				  thereby.
Statutory Authority
§§ 38.2-223, 38.2-514, 38.2-3516 through
					 38.2-3520, 38.2-3600 through 38.2-3609, 38.2-4214, and 38.2-4215 of the Code of
					 Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 170 - RULES GOVERNING MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 14VAC5-170-220:2 - APPENDIX B. FORM FOR REPORTING MEDICARE SUPPLEMENT POLICIES

Current through Register Vol. 40, No. 24, July 15, 2024
8/05
APPENDIX B
FORM FOR REPORTING MEDICARE SUPPLEMENT POLICIES
Company Name:_____________________________
Address:___________________________________
__________________________________________
Phone Number: ______________________________
Due March 1, annually
The purpose of this form is to report the following
				  information on each resident of Virginia who has in force more than one
				  Medicare supplement policy or certificate. The information is to be grouped by
				  individual policyholder.
Policy and Certificate #
Date of Issuance
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
___________________________________________
Signature
___________________________________________
Name and Title (please type)
___________________________________________
Date
Statutory Authority
§§ 12.1-13 and 38.2-223 of the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 170 - RULES GOVERNING MINIMUM STANDARDS FOR MEDICARE SUPPLEMENT POLICIES › Section 14VAC5-170-220:4 - APPENDIX D. NOTICE ABOUT ATTAINED AGE RATED MEDICARE SUPPLEMENT POLICIES

Current through Register Vol. 40, No. 24, July 15, 2024
Notice About Attained Age Rated Medicare Supplement
						  Policies
Under Medicare supplement policies or certificates that use
				  attained age rating, premiums automatically increase as you get older. You can
				  expect your premiums to increase each year (or other frequency as established
				  under the policy or certificate) due to changes in age.
Currently, the premiums for all ages under this policy (or
				  certificate) are as follows:
(include current premiums for all ages)
The premiums for other Medicare Supplement policies that are
				  issue age or community rated do not increase due to changes in your age
[The following sentence shall be in boldface type.]
				  While the cost for a Medicare Supplement policy that is based on attained age
				  may be lower than the cost of a Medicare Supplement policy that is issue age or
				  community rated at your present age, it is important to compare the potential
				  cost of these policies over the life of the policy.
Statutory Authority
§§ 12.1-13 and 38.2-223 of the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 180 - RULES GOVERNING UNDERWRITING PRACTICES AND COVERAGE LIMITATIONS AND EXCLUSIONS FOR ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) › Section 14VAC5-180-10 - Purpose

Current through Register Vol. 40, No. 24, July 15, 2024
The purpose of this chapter is to set forth rules and
				  procedural requirements that the Commission deems necessary to regulate
				  underwriting practices and policy limitations and exclusions with regard to HIV
				  infection and acquired immunodeficiency syndrome (AIDS).
Statutory Authority
§§ 38.2-223, 38.2-316, 38.2-508, 38.2-610,
					 38.2-3100.1 and 38.2-3401 of the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 180 - RULES GOVERNING UNDERWRITING PRACTICES AND COVERAGE LIMITATIONS AND EXCLUSIONS FOR ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) › Section 14VAC5-180-20 - Effective date

Current through Register Vol. 40, No. 24, July 15, 2024
A. No new
				application, policy, subscription contract or rider as described in
				14VAC5-180-30 shall be approved on
				or after May 1, 1990, unless it complies with this chapter.
B. No application shall be used and no
				policy, subscription contract or rider as described in
				14VAC5-180-30 shall be delivered,
				issued for delivery, reissued, renewed or extended in Virginia nor shall any
				term of the policy contract or rider be changed or premium adjustment be made,
				on or after May 1, 1990, unless it complies with this chapter.
Statutory Authority
§§ 38.2-223, 38.2-316, 38.2-508, 38.2-610,
					 38.2-3100.1 and 38.2-3401 of the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 180 - RULES GOVERNING UNDERWRITING PRACTICES AND COVERAGE LIMITATIONS AND EXCLUSIONS FOR ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) › Section 14VAC5-180-30 - Scope

Current through Register Vol. 40, No. 24, July 15, 2024
This chapter shall apply to all life and accident and
				  sickness insurance policies, and all health service plans and health
				  maintenance organization subscription contracts delivered or issued for
				  delivery in this Commonwealth, and to all applications, riders, and
				  underwriting procedures used in connection with such policies or subscription
				  contracts. This chapter shall apply to all such coverage delivered or issued
				  for delivery in Virginia, whether individual or group.
Statutory Authority
§§ 38.2-223, 38.2-316, 38.2-508, 38.2-610,
					 38.2-3100.1 and 38.2-3401 of the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 180 - RULES GOVERNING UNDERWRITING PRACTICES AND COVERAGE LIMITATIONS AND EXCLUSIONS FOR ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) › Section 14VAC5-180-40 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
As used in this chapter:
"Adverse underwriting decision" means any of the following
				  actions with respect to insurance transactions involving insurance coverage
				  that is individually underwritten:
1.
				A declination of insurance coverage,
2. A termination of insurance
				coverage,
3. Failure of an agent to
				apply for insurance coverage with a specific institution that an agent
				represents and that is requested by an applicant,
4. An offer to insure at higher than standard
				rates, or with limitations or exceptions or benefits other than those applied
				for.
"AIDS" means acquired immunodeficiency syndrome as defined by
				  the Centers for Disease Control of the United States Public Health
				  Service.
"HIV" means the human immunodeficiency virus.
"HIV-related test" means a test for exposure to or infection
				  with HIV, including antibody tests such as the ELISA or Western Blot assays, or
				  any future valid test approved by the Commission.
"Insurance" means any coverage provided by an insurer.
"Insurer" means any insurance company, health services plan,
				  or health maintenance organization licensed in this
				  Commonwealth.
Statutory Authority
§§ 38.2-223, 38.2-316, 38.2-508, 38.2-610,
					 38.2-3100.1 and 38.2-3401 of the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 180 - RULES GOVERNING UNDERWRITING PRACTICES AND COVERAGE LIMITATIONS AND EXCLUSIONS FOR ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) › Section 14VAC5-180-50 - Underwriting procedures

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				Insurers may underwrite for acquired immunodeficiency syndrome (AIDS) or HIV
				infection provided the underwriting procedures, including the questions used on
				the application for life or accident and sickness insurance coverage, are
				consistent and not unfairly discriminatory.
1. Questions relating to the applicant having
				or having been diagnosed as having AIDS or HIV infection are permissible if
				they are factual and designed to establish the existence of the
				condition.
2. An adverse
				underwriting decision is permissible if, during the underwriting process, it is
				revealed that the applicant has had positive HIV-related test results following
				the testing protocol as provided in subsection C, or has been diagnosed as
				having AIDS or HIV infection.
3. An
				adverse underwriting decision is not permissible if it is based solely on the
				presence of symptoms, as disclosed in an application for life or accident and
				sickness insurance coverage. An adverse underwriting decision is permissible,
				however, if the symptoms disclosed in the application for coverage are
				confirmed as being HIV-related through the use of medical records or
				HIV-related tests as provided in subsection C.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 180 - RULES GOVERNING UNDERWRITING PRACTICES AND COVERAGE LIMITATIONS AND EXCLUSIONS FOR ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) › Section 14VAC5-180-60 - Coverage limitations and exclusions

Current through Register Vol. 40, No. 24, July 15, 2024
A. The following policy limitations and
				exclusions are prohibited under this section:
1. Any life or accident and sickness
				insurance policy, any health services plan or health maintenance organization
				subscription contract or any rider used in connection with such policies or
				subscription contracts that excludes coverage for the treatment of HIV
				infection or Acquired Immunodeficiency Syndrome (AIDS) or complications or
				death resulting from such disease.
2. Any life or accident and sickness
				insurance policy, any health services plan or health maintenance organization
				subscription contract or any rider used in connection with such policies or
				subscription contracts that places a dollar limit on face amount of benefits
				payable for the treatment of HIV infection or Acquired Immunodeficiency
				Syndrome (AIDS) or complications or death resulting from such disease (other
				than the overall policy maximum or face amount).
3. A "preexisting condition" limitation
				related to HIV infection or Acquired Immunodeficiency Syndrome (AIDS) that is:
a. Defined to be more restrictive than the
				following:
(1) The existence of symptoms
				which would cause an ordinarily prudent person to seek diagnosis, care or
				treatment within a five year period preceding the effective date of the
				coverage of the insured person; or
(2) A condition for which medical advice or
				treatment, not including preventative educational counseling, was recommended
				by a physician or received from a physician within a five year period preceding
				the effective date of the coverage of the insured.
b. Based on the sole existence of a positive
				HIV-related test result, following the protocol as described in
				14VAC5-180-50 C, without the
				manifestation of symptoms or actual diagnosis of AIDS. Claims may not be denied
				as a preexisting condition solely on the existence of a positive HIV-related
				test result without the manifestation of symptoms or actual diagnosis of AIDS.
				Nothing in this subdivision shall be considered as prohibiting an insurance
				company from contesting a policy on the basis of material misrepresentation
				during the contestable period of the policy.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 180 - RULES GOVERNING UNDERWRITING PRACTICES AND COVERAGE LIMITATIONS AND EXCLUSIONS FOR ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) › Section 14VAC5-180-70 - Severability

Current through Register Vol. 40, No. 24, July 15, 2024
If any provisions of this chapter, or the application of it
				  to any person or circumstances, is held invalid, such invalidity shall not
				  affect other provisions or applications of this chapter which can be given
				  effect without the invalid provision or application, and to that end the
				  provisions of this chapter are severable.
Statutory Authority
§§ 38.2-223, 38.2-316, 38.2-508, 38.2-610,
					 38.2-3100.1 and 38.2-3401 of the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 190 - RULES GOVERNING THE REPORTING OF COST AND UTILIZATION DATA RELATING TO MANDATED BENEFITS AND MANDATED PROVIDERS › Section 14VAC5-190-10 - Purpose

Current through Register Vol. 40, No. 24, July 15, 2024
The purpose of this regulation is to implement §
									38.2-3419.1 of the Code of
				  Virginia with respect to mandated health insurance benefits and providers. This
				  regulation is designed to:
1. Provide
				the format for the reporting of costs and utilization associated with mandated
				benefits and providers;
2. Define
				the information that is required to be reported; and
3. Describe general data reporting elements
				related to costs and utilization associated with mandated benefits and mandated
				providers.
Statutory Authority: §§
											12.1-13 and
					 38.2-233 of the Code of
					 Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 190 - RULES GOVERNING THE REPORTING OF COST AND UTILIZATION DATA RELATING TO MANDATED BENEFITS AND MANDATED PROVIDERS › Section 14VAC5-190-20 - Scope

Current through Register Vol. 40, No. 24, July 15, 2024
This regulation shall apply to every health insurance issuer
				  licensed to issue policies of accident and sickness insurance, subscription
				  contracts, or evidences of coverage in this Commonwealth.
Statutory Authority: §§
											12.1-13 and
					 38.2-233 of the Code of
					 Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 190 - RULES GOVERNING THE REPORTING OF COST AND UTILIZATION DATA RELATING TO MANDATED BENEFITS AND MANDATED PROVIDERS › Section 14VAC5-190-30 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
The following words and terms when used in this chapter
				  shall have the following meanings unless the context clearly indicates
				  otherwise:
"Applicable policy" or "contract" means any accident and
				  sickness insurance policy providing hospital, medical and surgical, or major
				  medical coverage on an expense incurred basis or any accident and sickness
				  subscription contract or evidence of coverage or any health care plan provided
				  by a health maintenance organization issued or issued for delivery in the
				  Commonwealth of Virginia.
"Covered lives" means the total number of covered lives
				  reported by a health insurance issuer on the National Association of Insurance
				  Commissioners (NAIC) Supplemental Health Care Exhibit for Individual
				  Comprehensive Health Coverage, Small Group Employer Comprehensive Health
				  Coverage, and Large Group Employer Comprehensive Health Coverage combined as
				  defined in the NAIC Annual Statement Instructions, or equivalents in a
				  successor form.
"Health insurance issuer" means an insurance company or
				  insurance organization (including a health maintenance organization) that is
				  licensed to engage in the business of insurance in the Commonwealth and is
				  subject to the laws of the Commonwealth that regulate insurance within the
				  meaning of § 514(b)(2) of the Employee Retirement Income Security Act of
				  1974 ( 29 USC §
										1144(b)(2) ). Such term does
				  not include a group health plan.
"Incurred claims" means the total losses sustained whether
				  paid or unpaid.
"Mandated benefits" means those benefits that must be
				  included or offered in policies delivered or issued for delivery in the
				  Commonwealth as required by §§
									38.2-3409 through
				  38.2-3419 of the Code of
				  Virginia.
"Mandated providers" means those practitioners that are
				  listed in §§
									38.2-3408 and
				  38.2-4221 of the Code of
				  Virginia.
"Paid claims" means the aggregate of loss payments, less
				  deductions for all credits, except that no deduction is made for reinsurance
				  recoveries, during a given period.
"Reporting period" means the two individual calendar years
				  immediately preceding the May 1 reporting date, reported
				  separately.
Statutory Authority: §§
											12.1-13 and
					 38.2-233 of the Code of
					 Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 190 - RULES GOVERNING THE REPORTING OF COST AND UTILIZATION DATA RELATING TO MANDATED BENEFITS AND MANDATED PROVIDERS › Section 14VAC5-190-40 - Repealed

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §§
											12.1-13 and
					 38.2-233 of the Code of
					 Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 190 - RULES GOVERNING THE REPORTING OF COST AND UTILIZATION DATA RELATING TO MANDATED BENEFITS AND MANDATED PROVIDERS › Section 14VAC5-190-50 - Reporting and filing requirements

Current through Register Vol. 40, No. 24, July 15, 2024
A. Beginning May 1, 2018, and every other
				year thereafter, any health insurance issuer licensed to issue an applicable
				policy or contract in the Commonwealth of Virginia who reported greater than
				5,000 covered lives in Virginia during either of the individual calendar years
				comprising the reporting period shall file with the Bureau of Insurance a
				separate Form 190-A report for each calendar year in the reporting period.
B. The Form 190-A report may be
				obtained on the Bureau of Insurance's webpage at
https://scc.virginia.gov/pages/Mandated-Benefits-and-Mandated-Offers
and shall be filed electronically in accordance with the instructions that
				appear on the Bureau of Insurance's webpage.
Statutory Authority: 12.1-13 and 38.2-223 of the Code of
					 Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 190 - RULES GOVERNING THE REPORTING OF COST AND UTILIZATION DATA RELATING TO MANDATED BENEFITS AND MANDATED PROVIDERS › Section 14VAC5-190-60 - Annual notification and modification of reporting form

Current through Register Vol. 40, No. 24, July 15, 2024
The Bureau of Insurance shall be permitted to modify the data
				  requirements of the Form 190-A report and data reporting instructions on an
				  annual basis. Any such modifications, including the addition of new benefit or
				  provider categories as necessitated by the addition of new mandated benefit or
				  provider requirements to the Code of Virginia, as well as instructions related
				  to tracking and compiling data through medical procedure and diagnostic codes,
				  shall be provided to the health insurance issuers described in
				  14VAC5-190-50 A via letter or on
				  the Bureau of Insurance's webpage. Failure by an entity to receive or review
				  such annual notification shall not be grounds for noncompliance with the
				  reporting requirements set forth in this chapter.
Statutory Authority: §§
											12.1-13 and
					 38.2-233 of the Code of
					 Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 190 - RULES GOVERNING THE REPORTING OF COST AND UTILIZATION DATA RELATING TO MANDATED BENEFITS AND MANDATED PROVIDERS › Section 14VAC5-190-70 - Penalties

Current through Register Vol. 40, No. 24, July 15, 2024
The failure by a health insurance issuer to file a
				  substantially complete and accurate report as required by this chapter by the
				  required date may be considered a willful violation and is subject to an
				  appropriate penalty in accordance with §§
									38.2-218 and
				  38.2-219 of the Code of
				  Virginia.
Statutory Authority: §§
											12.1-13 and
					 38.2-233 of the Code of
					 Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 190 - RULES GOVERNING THE REPORTING OF COST AND UTILIZATION DATA RELATING TO MANDATED BENEFITS AND MANDATED PROVIDERS › Section 14VAC5-190-80 - Severability

Current through Register Vol. 40, No. 24, July 15, 2024
If any provision of these rules or the application thereof
				  to any person or circumstances is for any reason held to be invalid, the
				  remainder of these rules and the application of such provision to other persons
				  or circumstances shall not be affected thereby.
Statutory Authority
§§ 12.1-13, 38.2-223 and 38.2-3419.1 of the Code
					 of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 190 - RULES GOVERNING THE REPORTING OF COST AND UTILIZATION DATA RELATING TO MANDATED BENEFITS AND MANDATED PROVIDERS › Section 14VAC5-190-80:1 - APPENDIX A. FORM MB-1 INSTRUCTIONS AND INFORMATION (Repealed)

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §§
											12.1-13 and
					 38.2-233 of the Code of
					 Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 190 - RULES GOVERNING THE REPORTING OF COST AND UTILIZATION DATA RELATING TO MANDATED BENEFITS AND MANDATED PROVIDERS › Section 14VAC5-190-80:2 - APPENDIX B. CPT-4, ICD-9CM, AND UB-82 REFERENCES (Repealed)

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §§
											12.1-13 and
					 38.2-233 of the Code of
					 Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 190 - RULES GOVERNING THE REPORTING OF COST AND UTILIZATION DATA RELATING TO MANDATED BENEFITS AND MANDATED PROVIDERS › Form - FORMS (14VAC5-190)

Current through Register Vol. 40, No. 24, July 15, 2024
Form
				  190-A, Mandated Benefits Reporting Form for Virginia (undated)
,
http://www.scc.virginia.gov/boi/co/health/mandben.aspx
Statutory Authority: §§
											12.1-13 and
					 38.2-233 of the Code of
					 Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-10 - Purpose

Current through Register Vol. 40, No. 24, July 15, 2024
This chapter is designed to:
1. Promote the public interest;
2. Promote the availability of long-term care
				insurance coverage;
3. Protect
				applicants for long- term care insurance from unfair or deceptive sales or
				enrollment practices;
4. Promote
				public understanding and comparison of long-term care insurance coverage;
				and
5. Promote flexibility and
				innovation in the development of long-term care Insurance.
Statutory Authority
§§ 38.2-223 and 38.2-5200 through 38.2-5208 of
					 the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-20 - Contracts effective prior to April 1, 2003

Current through Register Vol. 40, No. 24, July 15, 2024
Except as otherwise specifically provided, each long-term
				  care insurance policy delivered or issued for delivery in this Commonwealth
				  prior to April 1, 2003, shall be subject to this chapter as it existed at the
				  time the policy was delivered or issued for delivery.
Statutory Authority
§§ 12.1-13 and 38.2-223 of the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-30 - Applicability and scope

Current through Register Vol. 40, No. 24, July 15, 2024
Except as otherwise specifically provided, this chapter
				  applies to all long-term care insurance policies delivered , issued for
				  delivery, or renewed in this Commonwealth, on or after September 1, 2015 , by
				  insurers, fraternal benefit societies, health services plans, health
				  maintenance organizations, or any other similar organization.
Statutory Authority: §§ 12.1-13, 38.2-223, and
					 38.2-5202 of the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-60 - Policy practices and provisions

Current through Register Vol. 40, No. 24, July 15, 2024
A. Renewability. The terms "guaranteed
				renewable" and "noncancellable" shall not be used in any individual long-term
				care insurance policy without further explanatory language in accordance with
				the disclosure requirements of
				14VAC5-200-70.
1. A policy issued to an individual shall not
				contain renewal provisions other than "guaranteed renewable" or "
				noncancellable."
2. The term
				"guaranteed renewable" may be used only when the insured has the right to
				continue the long-term care insurance in force by the timely payment of
				premiums and when the insurer has no unilateral right to make any change in any
				provision of the policy or rider while the insurance is in force, and cannot
				decline to renew, except that rates may be revised by the insurer on a class
				basis.
3. The term "noncancellable"
				may be used only when the insured has the right to continue the long-term care
				insurance in force by the timely payment of premiums during which period the
				insurer has no unilateral right to make any change in any provision of the
				insurance or in the premium rate.
4. The term "level premium" may only be used
				when the insurer does not have the right to change the premium.
5. In addition to the other requirements of
				this subsection, a qualified long-term care insurance contract shall be
				guaranteed renewable within the meaning of § 7702B (b)(1)(C) of the
				Internal Revenue Code of 1986.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-70 - Required disclosure provisions

Current through Register Vol. 40, No. 24, July 15, 2024
A. Renewability. Individual long-term care
				insurance policies shall contain a renewability provision.
1. The provision shall be appropriately
				captioned, shall appear on the first page of the policy, and shall clearly
				state that the coverage is guaranteed renewable or noncancellable. This
				subsection shall not apply to policies that do not contain a renewability
				provision and under which the right to renew is reserved solely to the
				policyholder.
2. A long-term care
				insurance policy or certificate, other than one where the insurer does not have
				the right to change the premium, shall include a clear and prominent statement
				in bold type and all capital letters that the premium rates may be
				increased.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-80 - Prohibition of post-claims underwriting

Current through Register Vol. 40, No. 24, July 15, 2024
A. All applications and enrollment forms for
				long-term care insurance policies or certificates except those which are
				guaranteed issue shall contain clear and unambiguous questions designed to
				ascertain the health condition of the applicant.
B. Requirements for applications or
				enrollment forms:
1. If an application or
				enrollment form for long-term care insurance contains a question that asks
				whether the applicant has had medication prescribed by a physician, it must
				also ask the applicant to list each medication that has been
				prescribed.
2. If the medications
				listed in such application or enrollment form were known by the insurer, or
				should have been known at the time of application, to be directly related to a
				medical condition for which coverage would otherwise be denied, then the policy
				or certificate shall not be rescinded for that condition, even if such
				condition is not otherwise disclosed in the application or enrollment
				form.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-90 - Minimum standards for home health care benefits in long-term care insurance policies

Current through Register Vol. 40, No. 24, July 15, 2024
A. A
				long-term care insurance policy or certificate may not, if it provides benefits
				for home health and community care services, limit or exclude benefits:
1. By requiring that the insured/claimant
				would need skilled care in a skilled nursing facility if home health care
				services were not provided;
2. By
				requiring that the insured/claimant first or simultaneously receive nursing
				and/or therapeutic services in a home or community setting before home health
				care services are covered;
3. By
				limiting eligible services to services provided by registered nurses or
				licensed practical nurses;
4. By
				requiring that a nurse or therapist provide services covered by the policy that
				can be provided by a home health aide, or other licensed or certified home care
				worker acting within the scope of his or her licensure or
				certification;
5. By excluding
				coverage for personal care services provided by a home health aide;
6. By requiring that the provision of home
				health care services be at a level of certification or licensure greater than
				that required by the eligible service;
7. By requiring that the insured/claimant
				have an acute condition before home health care services are covered;
8. By limiting benefits to services provided
				by Medicare-certified agencies or providers; or
9. By excluding coverage for adult day care
				services.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 200 - RULES GOVERNING LONG-TERM CARE INSURENCE › Section 14VAC5-200-100 - Requirement to offer inflation protection

Current through Register Vol. 40, No. 24, July 15, 2024
A. No insurer may offer a long-term care
				insurance policy unless the insurer also offers to the policyholder in addition
				to any other inflation protection offers the option to purchase a policy that
				provides for benefit levels to increase with benefit maximums or reasonable
				durations which are meaningful to account for reasonably anticipated increases
				in the costs of long-term care services covered by the policy. Insurers must
				offer to each policyholder, at the time of purchase, the option to purchase a
				policy with an inflation protection feature no less favorable than one of the
				following:
1. Increases benefit levels
				annually, in a manner so that the increases are compounded annually, at a rate
				not less than 5.0%;
2. Guarantees
				the insured individual the right to periodically increase benefit levels
				without providing evidence of insurability or health status; so long as the
				option for the previous period has not been declined. The amount of the
				additional benefit shall be no less than the difference between the existing
				policy benefit and that benefit compounded annually at a rate of at least 5.0%
				for the period beginning with the purchase of the existing benefit and
				extending until the year in which the offer is made; or
3. Covers a specified percentage of actual or
				reasonable charges and does not include a maximum specified indemnity amount or
				limit.