reglab/statecodes huggingface dataset:
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 101 - RULES GOVERNING LIFE AND HEALTH FORMS FILINGS › Section 14VAC5-101-60 - Form requirements

Current through Register Vol. 40, No. 24, July 15, 2024
The following requirements shall be met for each form
				  submitted for review or approval:
1.
				The form number shall appear in the lower left-hand corner of the first page of
				each form. It shall consist of numbers, letters, or a combination of both. The
				form number shall distinguish the form from all other forms used by the
				company.
2. The full licensed name
				of the company, including the address of the home office, shall appear in
				prominent print at the top of the cover page of any policy, application, or
				enrollment form. Examples of prominent print include print that is in all
				capital letters, bold, enlarged font, contrasting color, underlined, or
				otherwise differentiated from the other type in the form. The full licensed
				name of the company shall appear in prominent print on all other
				forms.
3. A marketing name or logo
				also may be used on the form, provided that the marketing name or logo does not
				mislead as to the identity of the company.
4. The cover page of a policy also shall
				include the address of an office that will administer the policy if different
				from the home office, a company telephone number, and company website
				address.
5. Each form shall be
				submitted in the final form in which it is to be marketed or issued,
				sufficiently completed in "John Doe" fashion to indicate how it is intended to
				be used.
6. Each form that is to be
				used in an electronic version shall be filed in a format that matches the
				electronic version exactly.
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 101 - RULES GOVERNING LIFE AND HEALTH FORMS FILINGS › Section 14VAC5-101-70 - Readability

Current through Register Vol. 40, No. 24, July 15, 2024
A. Each form
				submitted for review or approval shall be written in simplified language,
				logically and clearly arranged, printed in a legible format, and understandable
				to a person of average intelligence without special insurance knowledge or
				training.
B. A policy of more than
				three pages shall include a table of contents listing the principal sections
				and provisions and the pages on which they are found.
C. Defined words and terms shall be placed in
				a separate definition section that is clearly identified. A word or term that
				is used only in one section may be defined within that section.
D. A policy shall be divided into logically
				arranged sections with an appropriately named caption or heading for ease in
				locating desired content. Captions and headings shall be clearly set apart from
				the general text.
E. Any form
				submitted for review or approval shall be printed in at least 10-point type
				size.
F. Any policy shall achieve a
				minimum Flesch reading ease score of 50 or an equivalent score using another
				comparable test, unless otherwise specified by statute. The commission may
				approve an alternative to the Flesch reading ease score if it is determined to
				be comparable. The Flesch reading ease score shall be identified in the
				certificate of compliance for each policy.
G. A company may request an exception to the
				Flesch reading ease score. This request shall identify the specific reasons why
				the minimum standards have not been met and provide details of the policy's
				Flesch reading ease score test. The commission may except the policy if, in its
				sole discretion, it finds that a lower score:
(i) will provide a more accurate reflection
				of the readability of the policy;
(ii) is warranted by the nature of a
				particular policy or type or class of policies; or
(iii) is caused by certain policy language
				that is drafted to conform to the requirements of any state or federal law,
				regulation, or agency interpretation.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 101 - RULES GOVERNING LIFE AND HEALTH FORMS FILINGS › Section 14VAC5-101-80 - Variability

Current through Register Vol. 40, No. 24, July 15, 2024
A. Use of variable
				bracketed information shall be limited. All variable information shall be
				clear, easily understood, and fully explain each use of the variable
				language.
B. Administrative
				information, such as officer names, titles and signatures, contact information,
				or company logo may be presented as variable bracketed text.
C. Different types of benefits may be
				variable only for inclusion or exclusion within the form. The use of brackets
				within brackets is not permitted, except when variability is necessary to
				identify a period of time or other numeric value.
D. Each instance of variable text shall
				appear in brackets on a form and shall be separately and completely explained
				in detail in a Statement of Variability document. Each explanation of
				variability shall appear in the same order that it appears on the
				form.
E. Requests for revisions to
				a Statement of Variability contained in a previously approved filing shall be
				accomplished by notification in the original filing.
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 101 - RULES GOVERNING LIFE AND HEALTH FORMS FILINGS › Section 14VAC5-101-90 - Multiple employer welfare arrangement (MEWA) filings

Current through Register Vol. 40, No. 24, July 15, 2024
Any multiple employer welfare arrangement (MEWA) that has
				  registered with the commission as a licensed insurance company in accordance
				  with
				  14VAC5-410-40
				  shall also meet the form and rate filing requirements of §§
									38.2-316
				  and
				  38.2-316.1 of the
				  Code of Virginia.
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 101 - RULES GOVERNING LIFE AND HEALTH FORMS FILINGS › Section 14VAC5-101-100 - Out-of-state filings

Current through Register Vol. 40, No. 24, July 15, 2024
A. Any
				company that wishes to deliver a certificate of insurance to any person located
				in this Commonwealth in connection with a policy issued outside of Virginia
				shall indicate the type of group (i) as defined in §
									38.2-3318.1
				or
				38.2-3521.1
				of the Code of Virginia as applicable or (ii) a nondefined or discretionary
				group to which the policy is issued.
1.  If
				the group is defined in accordance with §
										38.2-3318.1
				or
				38.2-3521.1
				of the Code of Virginia as applicable, the company shall file for use any form
				that will be delivered in Virginia along with documentation that substantiates
				that the issuing state's filing requirements have been met. In addition, a
				certification from the company is required indicating that the group insurance
				coverage marketed to residents of this Commonwealth will comply with the
				provisions of §
										38.2-3318.1
				or
				38.2-3521.1
				of the Code of Virginia as applicable.
2.
				 If the group is nondefined or discretionary and the state of
				issue has substantially similar laws to Virginia in accordance with subsection
				B of this section , the company shall file for use any form that will be
				delivered in Virginia along with documentation that substantiates that the
				issuing state's filing requirements have been met. In addition, a certification
				from the company is required indicating that the group insurance coverage
				marketed to residents of this Commonwealth complies with the requirements of
				subsection B this section.
3.  If
				the group is nondefined or discretionary and the state of issue does not have
				substantially similar laws to Virginia, the company shall file for approval any
				form that will be delivered in this Commonwealth in accordance with §
										38.2-316
				of the Code of Virginia.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 101 - RULES GOVERNING LIFE AND HEALTH FORMS FILINGS › Section 14VAC5-101-110 - Certificate of compliance

Current through Register Vol. 40, No. 24, July 15, 2024
Each form filing shall include a statement identical to the
				  following that is signed by an officer of the company:
The Flesch reading ease score of the filed policy form is
				  _________.
I represent that a review of the enclosed form has been
				  conducted, and I certify that, to the best of my knowledge and belief, each
				  form submitted is consistent and complies with the requirements of Title 38.2
				  of the Code of Virginia and the applicable rules and regulations. I understand
				  that a failure to comply with these requirements will result in a disapproval
				  of the filing.
_______________________________
Signature of Officer
_______________________________
Printed Name
_______________________________
Title
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 101 - RULES GOVERNING LIFE AND HEALTH FORMS FILINGS › Section 14VAC5-101-120 - Severability

Current through Register Vol. 40, No. 24, July 15, 2024
If any provision of this chapter or its application to any
				  person or circumstance is for any reason held to be invalid by a court, the
				  remainder of this chapter and the application of the provisions to other
				  persons or circumstances shall not be affected.
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 130 - RULES GOVERNING THE FILING OF RATES FOR INDIVIDUAL AND CERTAIN GROUP ACCIDENT AND SICKNESS INSURANCE POLICY FORMS › Section 14VAC5-130-10 - Purpose

Current through Register Vol. 40, No. 24, July 15, 2024
The purposes of this chapter are to (i) implement procedures
				  for the filing or filing and approval of rates for individual and group
				  accident and sickness insurance policy forms and (ii) establish minimum loss
				  ratios to assure that the benefits provided by such policy forms are or are
				  anticipated to be reasonable in relation to the premiums
				  charged.
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 130 - RULES GOVERNING THE FILING OF RATES FOR INDIVIDUAL AND CERTAIN GROUP ACCIDENT AND SICKNESS INSURANCE POLICY FORMS › Section 14VAC5-130-30 - Scope

Current through Register Vol. 40, No. 24, July 15, 2024
A. This chapter
				applies to :
1. All individual and group
				accident and sickness insurance policies, subscriber contracts of health
				maintenance organizations or health services plans, dental plans, and
				optometric plans delivered or issued for delivery in this
				Commonwealth.
2. All health
				insurance coverage issued in the individual and small group markets.
3. Individual and group Medicare supplement
				insurance policies and group subscriber contracts of health maintenance
				organizations or health services plans providing Medicare supplement coverage
				delivered or issued for delivery in this Commonwealth.
4. Individual and group long-term care
				policies issued before October 1, 2003.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 130 - RULES GOVERNING THE FILING OF RATES FOR INDIVIDUAL AND CERTAIN GROUP ACCIDENT AND SICKNESS INSURANCE POLICY FORMS › Section 14VAC5-130-50 - General rules on rate filing; experience records and data

Current through Register Vol. 40, No. 24, July 15, 2024
A. Every policy,
				rider, or endorsement form affecting benefits which is submitted for approval
				shall be accompanied by a rate filing unless such rider or endorsement form
				does not require a change in the rate. Any subsequent addition to or change in
				rates applicable to such policy, rider, or endorsement form shall also be
				filed.
B. Each rate submission
				shall include an actuarial memorandum describing the basis on which rates and
				rating factors were determined and shall describe and provide the calculation
				of the anticipated loss ratio. Except for individual and small employer group
				health insurance coverage, interest at a rate consistent with that assumed in
				the original determination of premiums shall be used in the calculation of this
				loss ratio. Each rate submission must also include a certification by a
				qualified actuary that to the best of the actuary's knowledge and judgment, the
				rate filing is in compliance with the applicable laws and regulations of this
				Commonwealth, and that the benefits are reasonable in relation to the
				premiums.
C. Insurers shall
				maintain records of earned premiums and incurred benefits for each calendar
				year for each policy form, including data for rider and endorsement forms which
				are used with the policy form, on the same basis, including all reserves, as
				required for the Accident and Health Policy Experience Exhibit. Separate data
				may be maintained for each rider or endorsement form to the extent appropriate.
				Experience under forms which provide substantially similar coverage may be
				combined. The data shall be for each calendar year of experience since the year
				the form was first issued.
D. In
				determining the credibility and appropriateness of experience data, due
				consideration must be given to all relevant factors, such as:
1. Statistical credibility of premiums and
				benefits, e.g., low exposure, low loss frequency.
2. Experienced and projected trends relative
				to the kind of coverage, for example, inflation in medical expenses, economic
				cycles affecting disability income experience.
3. The concentration of experience at early
				policy durations where select morbidity and preliminary term reserves are
				applicable and where loss ratios are expected to be substantially lower than at
				later policy durations.
4. The mix
				of business by risk classification.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 130 - RULES GOVERNING THE FILING OF RATES FOR INDIVIDUAL AND CERTAIN GROUP ACCIDENT AND SICKNESS INSURANCE POLICY FORMS › Section 14VAC5-130-60 - Filing of rates for a new policy form

Current through Register Vol. 40, No. 24, July 15, 2024
A. Each rate submission shall include (i) the
				applicable policy or certificate form, application, and endorsements required
				by §
									38.2-316
				of the Code of Virginia, (ii) a rate sheet, (iii) an actuarial memorandum, and
				(iv) all information required in SERFF.
B. The actuarial memorandum shall contain the
				following information:
1. A description of
				the type of policy , including benefits, renewability, general marketing
				method, and issue age limits.
2. A
				description of how rates and rating factors were determined, including the
				description and source of each assumption used.
3. The expected average annual premium per
				policy and per anticipated member.
4. The anticipated loss ratio and a
				description of how it was calculated.
5. The minimum anticipated loss ratio
				presumed reasonable in this chapter, as specified in
				14VAC5-130-65.
6. If the anticipated loss ratio in
				subdivision 4 of this subsection is less than the minimum loss ratio in
				subdivision 5 of this subsection, supporting documentation for the use of such
				premiums shall also be included.
7.
				A certification by a qualified actuary that, to the best of the actuary's
				knowledge and judgment, the rate filing is in compliance with the applicable
				laws and regulations of this Commonwealth and the premiums are reasonable in
				relation to the benefits provided.
8. For individual or small employer group
				health insurance coverage, a certification by a qualified actuary to include
				(i) the methodology used to calculate the AV metal value for each plan; (ii)
				the appropriateness of the essential health benefit portion of premium upon
				which advanced payment of premium tax credits are based; (iii) the development
				of the index rate in accordance with federal regulations and the development of
				plan specific premium rates using allowable modifiers to the index rate; and
				(iv) the geographic rating factors, which should reflect differences only in
				the costs of delivery (which can include unit cost and provider practice
				pattern differences) and not differences in population morbidity by geographic
				area.
9. For student health
				insurance coverage, a certification by a qualified actuary to include the
				methodology used to calculate an AV level of coverage that meets a minimum
				60%.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 130 - RULES GOVERNING THE FILING OF RATES FOR INDIVIDUAL AND CERTAIN GROUP ACCIDENT AND SICKNESS INSURANCE POLICY FORMS › Section 14VAC5-130-65 - Reasonableness of benefits in relation to initial premiums

Current through Register Vol. 40, No. 24, July 15, 2024
A. Benefits shall be deemed reasonable in
				relation to premiums provided the anticipated loss ratio of the policy form,
				including riders and endorsements, is at least as great as specified in this
				subsection:
1. If the expected average annual
				premium is at least $200 but less than $1,000:
Type of Coverage
Renewal Clause
OR
CR
GR
NC
Other
Hospital Confinement Indemnity
n/a
n/a
55%
50%
n/a
Disability Income Protection, Accident Only,
							 Specified Disease and Other, whether paid on an expense incurred or indemnity
							 basis
60%
55%
50%
45%
60%
Short-term Limited Duration
n/a
n/a
n/a
n/a
60%
Definitions of renewal clause:
OR - Optionally renewable: individual policy renewal is at
				  the option of the insurance company.
CR - Conditionally renewable: renewal can be declined by the
				  insurance company only for stated reasons other than deterioration of health or
				  renewal can be declined on a geographic territory basis.
GR - Guaranteed renewable: renewal cannot be declined by the
				  insurance company for any reason, but the insurance company can revise rates on
				  a class basis.
NC - Noncancellable: renewal cannot be declined nor can rates
				  be revised by the insurance company.
Other - Any other renewal or nonrenewal clauses .
2. If the expected average annual
				premium is $100 or more but less than $200, subtract five percentage points
				from the numbers in the table in subdivision 1 of this subsection.
3. If the expected average annual premium is
				less than $100, subtract 10 percentage points from the numbers in the table in
				subdivision 1 of this subsection.
4. If the expected average annual premium is
				$1,000 or more, add five percentage points to the numbers in the table in
				subdivision 1 of this subsection.
5. For individual or group Medicare
				supplement policies, the loss ratios are identified in
				14VAC5-170-120
				A.
6. Notwithstanding subdivisions
				1 through 4 of this subsection, all individual health insurance coverage shall
				be originally priced to meet a minimum 75% loss ratio and, except for student
				health insurance coverage such coverage shall be guaranteed renewable or
				noncancellable.
7. Notwithstanding
				subdivisions 1 through 4 of this subsection, all small employer group health
				insurance coverage shall be originally priced to meet a minimum 75% loss ratio
				and shall be guaranteed renewable or noncancellable.
The above anticipated loss ratio standards do not apply to a
				  type of coverage where such standards are in conflict with specific statutes or
				  regulations.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 130 - RULES GOVERNING THE FILING OF RATES FOR INDIVIDUAL AND CERTAIN GROUP ACCIDENT AND SICKNESS INSURANCE POLICY FORMS › Section 14VAC5-130-75 - Reasonableness of benefits in relation to revised premiums

Current through Register Vol. 40, No. 24, July 15, 2024
A. For individual accident and sickness
				insurance that is "excepted benefits" as defined in §
									38.2-3431
				of the Code of Virginia and Medicare supplement insurance, with respect to
				filings of rate revisions for a previously approved form, benefits shall be
				deemed reasonable in relation to premiums provided that both subdivisions 1 and
				2 of this subsection shall be at least as great as the standards in
				14VAC5-130-70
				B 11.
1. The anticipated loss ratio over the
				entire period for which the revised rates are computed to provide coverage;
				and
2. The ratio of (a) to (b)
				where (a) is the sum of the accumulated benefits, from the original effective
				date of the form to the effective date of the revision, and the present value
				of future benefits, and (b) is the sum of the accumulated premiums from the
				original effective date of the form to the effective date of the revision and
				the present value of future premiums.
Present values shall be taken over the entire period for
				  which the revised rates are computed to provide coverage. Accumulated benefits
				  and premiums shall include an explicit estimate of benefits and premiums from
				  the last accounting date to the effective date of the revision. Interest, at a
				  rate consistent with that assumed in the original determination of premiums
				  shall be used in the calculation of this loss ratio.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 130 - RULES GOVERNING THE FILING OF RATES FOR INDIVIDUAL AND CERTAIN GROUP ACCIDENT AND SICKNESS INSURANCE POLICY FORMS › Section 14VAC5-130-81 - Risk pools and index rate

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				This section shall only apply to individual or small employer group health
				insurance coverage, except for grandfathered plans and student health insurance
				coverage.
B. An insurer shall
				consider the claims experience of all individual health insurance coverage
				members, other than those in grandfathered plans and student health insurance
				coverage, to be members of a single risk pool.
C. An insurer shall consider the claims
				experience of all small employer group health insurance coverage members, other
				than those in grandfathered plans, to be members of a single risk
				pool.
D. Each plan year or policy
				year, as applicable, an insurer shall establish an index rate based on the
				total combined claims costs for providing essential health benefits within the
				single risk pool . The index rate may be adjusted on a market-wide basis based
				on the total expected market-wide payments and charges under the risk
				adjustment and reinsurance programs in this Commonwealth and the health benefit
				exchange user fees. The premium rate for all of the insurer's plans shall use
				the applicable index rate, as adjusted in accordance with subsection E of this
				section.
E. An insurer may vary
				premium rates for a particular plan from its index rate for a relevant state
				market based only on the following actuarially justified plan-specific factors
				in accordance with
				45 CFR
				156.80(d)(2):
1. Actuarial value and cost-sharing design of
				the plan.
2. The plan's provider
				network, delivery system characteristics, and utilization management
				practices.
3. Benefits provided
				under the plan that are in addition to the essential health benefits.
4. Administrative costs, excluding health
				benefit exchange user fees.
5. Only
				catastrophic plans may be adjusted for the expected impact of the specific
				eligibility categories for those plans.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 130 - RULES GOVERNING THE FILING OF RATES FOR INDIVIDUAL AND CERTAIN GROUP ACCIDENT AND SICKNESS INSURANCE POLICY FORMS › Section 14VAC5-130-90 - Monitoring of experience

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
				commission may prescribe procedures for the effective monitoring of actual
				experience under any form subject to this chapter.
B. The commission may request information
				subsequent to approval of a policy form, rate, or rate revision so that it may
				determine whether premium rates are reasonable in relation to the benefits
				provided as specified herein in
				14VAC5-130-65
				and
				14VAC5-130-75.
C. If the commission finds that the premium
				rate filed in accordance with this chapter is or will not meet the originally
				filed and approved loss ratio, the commission may require appropriate rate
				adjustments, premium refunds or premium credits as deemed necessary for the
				coverage to conform with the minimum loss ratio standards set forth in
				14VAC5-130-65,
				and which are expected to result in a loss ratio at least as great as that
				originally anticipated in the rates used to produce current rates by the
				insurer for the coverage. The commission may take into consideration any
				previous or expected premium refunds or credits. Detailed supporting documents
				will be required as necessary to justify the adjustment.
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 130 - RULES GOVERNING THE FILING OF RATES FOR INDIVIDUAL AND CERTAIN GROUP ACCIDENT AND SICKNESS INSURANCE POLICY FORMS › Section 14VAC5-130-100 - Severability

Current through Register Vol. 40, No. 24, July 15, 2024
If any provision of this chapter or the application to any
				  person or circumstance is for any reason held to be invalid, the remainder of
				  this chapter and the application of such provision to other persons or
				  circumstances shall not be affected .
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 135 - RULES GOVERNING INDIVIDUAL AND SMALL GROUP MARKET HEALTH BENEFIT PLANS › Section 14VAC5-135-10 - Applicability and scope

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				This chapter (14VAC5-135) implements the provisions of Chapters 34 (§
				38.2-3400 et seq.) and 35 (§ 38.2-3500 et seq.) of Title 38.2 of the Code
				of Virginia and sets forth the standards for compliance with the federal
				Affordable Care Act.
B. This
				chapter shall apply to all individual and small group market health benefit
				plans delivered or issued for delivery in this Commonwealth.
C. Health benefit plans filed in this
				Commonwealth and approved for sale in a health benefit exchange pursuant to
				§ 38.2-326 of the Code of Virginia shall comply with the provisions of
				this chapter.
D. This chapter shall
				not apply to a grandfathered health plan, as defined in § 38.2-3438 of the
				Code of Virginia, for as long as the plan maintains its status in accordance
				with federal regulations.
E. This
				chapter shall not apply to excepted benefits policies, as defined in §
				38.2-3431 of the Code of Virginia.
F. This chapter shall not apply to a
				short-term limited-duration medical plan, as defined in § 38.2-3407.21 of
				the Code of Virginia.
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 135 - RULES GOVERNING INDIVIDUAL AND SMALL GROUP MARKET HEALTH BENEFIT PLANS › Section 14VAC5-135-30 - General policy requirements

Current through Register Vol. 40, No. 24, July 15, 2024
A. Each health benefit plan shall contain a
				guaranteed renewability provision in accordance with § 38.2-3430.7 or
				38.2-3432.1 of the Code of Virginia. The provision shall appear on the first
				page of the policy.
B. Each health
				benefit plan shall contain a termination, cancellation, or discontinuation of
				coverage policy provision in accordance with § 38.2-3430.7 or 38.2-3432.1
				of the Code of Virginia.
C. Each
				health benefit plan shall contain a provision for grace periods:
1. An individual health benefit plan shall
				contain a grace period of not less than 31 days after the initial premium is
				paid. Further, in accordance with
				45 CFR
				156.270(d), an individual
				health benefit plan offered on the exchange shall also contain language that an
				enrollee receiving advance payments of the premium tax credit is instead
				subject to a grace period of three consecutive months, during which time the
				health carrier shall pay all appropriate claims for services rendered to the
				enrollee during the first month of the grace period and may pend claims for
				services rendered to the enrollee in the second and third months of the grace
				period. If the enrollee exhausts the three-month grace period, the health
				carrier shall terminate the policy effective the last day of the first month of
				the three-month grace period.
2. A
				group health benefit plan shall contain a grace period of not less than 31 days
				after the initial premium is paid.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 135 - RULES GOVERNING INDIVIDUAL AND SMALL GROUP MARKET HEALTH BENEFIT PLANS › Section 14VAC5-135-40 - Student health insurance coverage

Current through Register Vol. 40, No. 24, July 15, 2024
A. For purposes of this section, "student
				health insurance coverage" means a type of individual health insurance coverage
				offered in the individual market that (i) is provided pursuant to a written
				agreement between an institution of higher education, as defined by the Higher
				Education Act of 1965 (P.L.
				89-329), and a health carrier and provided to
				students enrolled in that institution of higher education and their covered
				dependents; (ii) does not make health insurance coverage available other than
				in connection with enrollment as a student or as a covered dependent of a
				student of the institution of higher education; and (iii) does not condition
				eligibility for health insurance coverage on any health status-related factor
				related to a student or a covered dependent of the student.
B. Student health insurance coverage is
				subject to the requirements of the ACA, including essential health benefits,
				mental health parity, and the requirements of this chapter, except as noted in
				this section.
C. Student health
				insurance coverage is exempt from the guaranteed availability requirements of
				§ 38.2-3430.3 of the Code of Virginia and the guaranteed renewability
				requirements of § 38.2-3430.7 of the Code of Virginia.
D. Student health insurance coverage is not
				subject to the single risk pool requirement outlined in § 1312(c) of the
				ACA.
E. Student health insurance
				coverage premium rates may be based on a school-specific community
				rating.
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 135 - RULES GOVERNING INDIVIDUAL AND SMALL GROUP MARKET HEALTH BENEFIT PLANS › Section 14VAC5-135-50 - Prohibitions, limitations, and disclosures

Current through Register Vol. 40, No. 24, July 15, 2024
A. A health carrier shall not discriminate on
				the basis of race, color, national origin, disability, age, sex, gender
				identity, gender expression, sexual orientation, or status as a transgender
				individual. Nothing in this section shall be construed to prevent a health
				carrier from appropriately utilizing reasonable medical management techniques
				including medical necessity.
B. If
				a health carrier offers an optional benefit to a health benefit plan, the
				health carrier may file a separate schedule that includes the additional
				benefit and identify the health benefit plan to which the schedule applies. A
				different plan identification is necessary to distinguish the health benefit
				plan with the additional benefit.
C. A health carrier may offer a health
				benefit plan that does not include pediatric oral health benefits if:
1. The health carrier is reasonably assured
				that pediatric oral health benefits are available to the purchaser of the
				health benefit plan in accordance with § 38.2-3451 B of the Code of
				Virginia, and
2. The plan contains
				the following statement on the first page of the policy and bold:
"This policy does not provide the ACA-required pediatric oral
				  health benefits."
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 135 - RULES GOVERNING INDIVIDUAL AND SMALL GROUP MARKET HEALTH BENEFIT PLANS › Section 14VAC5-135-60 - Severability

Current through Register Vol. 40, No. 24, July 15, 2024
If any provision of this chapter or its application to any
				  person or circumstance is for any reason held to be invalid, the remainder of
				  the chapter and the application of the provisions to other persons or
				  circumstances shall not be affected.
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 141 - RULES GOVERNING ACCIDENT AND SICKNESS EXCEPTED BENEFITS POLICIES; SHORT-TERM LIMITED DURATION INSURANCE › Section 14VAC5-141-10 - Applicability and scope

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				This chapter implements the provisions of Chapters 34 (§ 38.2-3400 et
				seq.) and 35 (§ 38.2-3500 et seq.) of Title 38.2 of the Code of Virginia
				as it applies to excepted benefits as defined in § 38.2-3431 of the Code
				of Virginia, 45 CFR §
										146.145, and
				45 CFR 148.220, as well as
				short-term limited-duration insurance.
B. This chapter applies to all individual and
				group market insurance policies delivered or issued for delivery in Virginia
				that qualify as accident and sickness excepted benefits.
C. This chapter applies to all short-term
				limited-duration insurance delivered or issued for delivery in Virginia,
				including a certificate delivered in Virginia that is issued under a short-term
				limited-duration plan in any other jurisdiction.
D. This chapter outlines the types of
				accident and sickness excepted benefits policies and the allowable combinations
				of such policies that may be approved for use in Virginia. No other
				combinations or types of such policies may be filed without prior approval by
				the commission.
E. This chapter
				does not apply to Medicare Supplement policies, which are governed under Rules
				Governing Minimum Standards for Medicare Supplement Policies (14VAC5-170) and
				long-term care insurance, which is governed under Rules Governing Long-Term
				Care Insurance (14VAC5-200).
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 141 - RULES GOVERNING ACCIDENT AND SICKNESS EXCEPTED BENEFITS POLICIES; SHORT-TERM LIMITED DURATION INSURANCE › Section 14VAC5-141-20 - 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:
"Accident" means an unintentional or unexpected event or
				  circumstance that results in injury.
"Accident only coverage" means a policy that provides
				  benefits for accidental injury.
"Accidental injury" means bodily injury sustained by the
				  insured that is the direct result of an accident independent of disease,
				  infirmity, or any other cause. "Accidental injury" shall not include words that
				  establish an accidental means test or use words such as "external," "violent,"
				  "visible wounds," or similar words of description or characterization.
"Commission" means the State Corporation Commission.
"Disability income insurance" means a policy that provides
				  for weekly or monthly periodic payments for a specified period during the
				  continuance of the insured's partial or total disability resulting from either
				  sickness or injury or a combination of the two.
"Elimination period" means a period of time after coverage
				  begins and is between the date of loss and when benefits commence. An
				  elimination period may only be included in a disability income policy or a
				  short-term convalescent care policy, unless otherwise specified in this
				  chapter.
"Excepted benefits" has the same meaning as in §
				  38.2-3431 of the Code of Virginia. For purposes of this regulation:
1. The following benefits are excepted in all
				circumstances:
a. Coverage only for accident
				(including accidental death and dismemberment); or
b. Disability income insurance.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 141 - RULES GOVERNING ACCIDENT AND SICKNESS EXCEPTED BENEFITS POLICIES; SHORT-TERM LIMITED DURATION INSURANCE › Section 14VAC5-141-40 - Prohibitions, limitations and disclosures

Current through Register Vol. 40, No. 24, July 15, 2024
A. No excepted benefits policy or short-term
				limited-duration insurance policy may be advertised, offered for sale, or sold
				as minimum essential coverage.
B. A
				policy shall not have a waiting period that exceeds 30 days, unless otherwise
				specified in this chapter.
C. If a
				policy contains a preexisting condition exclusion, it shall conform to the
				requirements included in the definition of "preexisting condition" in this
				chapter, unless otherwise specified in this chapter.
D. Any limit or reduction of coverage or
				benefits for specifically named or described preexisting conditions that goes
				beyond the limitations in subsection C of this section or extrahazardous
				activity that is a condition of issuance, renewal, or reinstatement requires a
				signed acceptance by the policyholder and shall be attached to the
				policy.
E. Except for riders or
				endorsements by which the insurer fulfills a request made in writing by the
				policyholder, an insurer shall not reduce or eliminate benefits or coverage
				except at reinstatement or renewal. After the date of policy issue and during
				the policy term, any rider or endorsement that increases benefits or coverage
				with an increase in premium shall be agreed to in writing by the policyholder,
				except if the increased benefits or coverage is required by law.
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 141 - RULES GOVERNING ACCIDENT AND SICKNESS EXCEPTED BENEFITS POLICIES; SHORT-TERM LIMITED DURATION INSURANCE › Section 14VAC5-141-50 - Accident

Current through Register Vol. 40, No. 24, July 15, 2024
A. Accident only
				coverage is a benefit provided for accidental bodily injury sustained by the
				insured person. Accident only coverage shall not contain a waiting
				period.
B. Accident only coverage
				may be filed in combination with the following:
1. Accidental death and
				dismemberment;
2. Disability
				income; or
3. Hospital indemnity or
				fixed indemnity.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 141 - RULES GOVERNING ACCIDENT AND SICKNESS EXCEPTED BENEFITS POLICIES; SHORT-TERM LIMITED DURATION INSURANCE › Section 14VAC5-141-60 - Disability income insurance

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				Disability income insurance is a policy that provides for weekly or monthly
				periodic payments for a specified period during the continuance of partial or
				total disability resulting from either sickness or injury or a combination of
				the two.
B. Disability income
				insurance may be filed in combination with the following:
1. Accident only coverage;
2. Accidental death and dismemberment;
				or
3. Hospital indemnity or fixed
				indemnity.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 141 - RULES GOVERNING ACCIDENT AND SICKNESS EXCEPTED BENEFITS POLICIES; SHORT-TERM LIMITED DURATION INSURANCE › Section 14VAC5-141-70 - Limited scope benefits - dental, vision, and hearing

Current through Register Vol. 40, No. 24, July 15, 2024
A. Limited scope dental, limited scope
				vision, and limited scope hearing are plans that provide for benefits primarily
				for the treatment of the mouth, eyes, and ears, respectively.
B. Limited scope dental, limited scope
				vision, and limited scope hearing plans may be provided either as separate
				policies, certificates, or contracts of insurance, or not part of an integral
				group health plan. Benefits are not part of an integral group health plan if
				the participant has the right to opt-out of coverage, or if claims for the
				benefits are administered under a separate contract from the claims
				administration for any other benefits under the group health plan.
C. Except for diagnostic and preventive
				benefits, a limited scope dental plan may apply waiting periods that exceed 30
				days but no longer than 12 months to specific services or benefits. A waiting
				period not to exceed 24 months may be applied to orthodontic
				services.
D. For any limited scope
				dental plan to be recognized as meeting essential health benefits in accordance
				with § 38.2-3451 of the Code of Virginia and be treated as a qualified
				health plan in accordance with
				45 CFR
				155.1065, pediatric dental essential health
				benefits shall be included in the plan.
E. In addition to the notice required in
				14VAC5-141-30 A, any limited scope
				dental plan that is not an exchange certified stand-alone dental plan shall
				include the following language on the face of the policy:
"THIS IS A STAND-ALONE DENTAL POLICY THAT IS NOT EXCHANGE
				  CERTIFIED AND MAY NOT PROVIDE MINIMUM ESSENTIAL PEDIATRIC DENTAL
				  BENEFITS."
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 141 - RULES GOVERNING ACCIDENT AND SICKNESS EXCEPTED BENEFITS POLICIES; SHORT-TERM LIMITED DURATION INSURANCE › Section 14VAC5-141-80 - Limited scope benefits - accident and sickness insurance while traveling

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				Limited scope accident and sickness insurance while traveling is a separate
				policy providing accident and sickness benefits only for the limited duration
				of an insured's trip.
B. A limited
				scope accident and sickness insurance while traveling policy:
1. Shall not contain preexisting condition
				exclusions;
2. Shall not contain a
				waiting period;
3. Shall not
				contain a deductible applied to benefits;
4. Shall not coordinate benefits with any
				other accident and sickness policy;
5. Shall not be renewable;
6. Shall not include benefits for trip
				interruption or trip cancellation; and
7. Shall provide accident and sickness
				benefits only for the limited duration of an insured's trip.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 141 - RULES GOVERNING ACCIDENT AND SICKNESS EXCEPTED BENEFITS POLICIES; SHORT-TERM LIMITED DURATION INSURANCE › Section 14VAC5-141-90 - Limited scope benefits - short-term convalescent care

Current through Register Vol. 40, No. 24, July 15, 2024
A. A short-term convalescent care policy may
				include care provided in a nursing home, assisted living facility, hospice,
				adult day care center, or home. A short-term convalescent care policy is a
				policy with a maximum lifetime benefit period that does not exceed 364 days and
				that is provided under a separate policy, certificate, or contract of
				insurance.
B. There is no
				coordination of benefits with any other accident and sickness policy.
C. A short-term convalescent care policy
				shall contain the following provisions:
1.
				Eligibility for benefits shall be based on loss due to accident or sickness and
				loss of functional capacity or cognitive impairment.
2. Once the maximum benefit period under the
				policy has been exhausted, the policy may not be renewed.
3. If a policy contains a period in which
				benefits may be restored, the maximum period of time between benefit periods
				shall be no more than 180 days.
4.
				If a policy conditions benefits on an insured's inability to perform activities
				of daily living or on cognitive impairment, such requirements shall be
				defined.
5. Eligibility for
				benefits shall not be more restrictive than the presence of cognitive
				impairment or a deficiency of no more than two activities of daily
				living.
6. Reimbursement for any
				covered service that is legally performed by a person licensed to perform such
				services may not be denied.
Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 141 - RULES GOVERNING ACCIDENT AND SICKNESS EXCEPTED BENEFITS POLICIES; SHORT-TERM LIMITED DURATION INSURANCE › Section 14VAC5-141-100 - Limited scope benefits - group blanket policies

Current through Register Vol. 40, No. 24, July 15, 2024
A. A group blanket insurance policy is a
				policy of limited accident and sickness insurance that provides coverage for
				specified circumstances and a specific class of persons defined in the policy
				issued to a master policyholder. Such policy does not specifically name persons
				covered, by certificate or otherwise, although a statement of the coverage
				provided may be given, or required by the policy to be given, to eligible
				persons.
B. An individual
				application is not required from a person covered under a blanket insurance
				policy.
C. No insurer issuing a
				blanket insurance policy shall be required to furnish a certificate to each
				person covered by the policy.
D. A
				blanket insurance policy to be issued or issued for delivery in Virginia shall
				comply with the requirements of § 38.2-3521.2 of the Code of
				Virginia.
Statutory Authority: §§ 12.1-13 and 38.2-223 of
					 the Code of Virginia.