Virginia Administrative Code › Title 14 - INSURANCE › Agency 5 - STATE CORPORATION COMMISSION, BUREAU OF INSURANCE › Chapter 211 - RULES GOVERNING HEALTH MAINTENANCE ORGANIZATIONS › Part IV - Services › Section 14VAC5-211-160 - Basic health care services

Current through Register Vol. 40, No. 24, July 15, 2024
A. A health maintenance organization that
				  offers coverage in the large group market shall provide, or arrange for the
				  provision of, as a minimum, basic health care services. These services shall
				  include the following:
1. Inpatient hospital
				  and physician services. Medically necessary hospital and physician services
				  affording inpatient treatment to enrollees in a licensed hospital for a minimum
				  of 90 days per contract or calendar year. Hospital services include room and
				  board; general nursing care; special diets when medically necessary; use of
				  operating room and related facilities; use of intensive care unit and services;
				  x-ray, laboratory, and other diagnostic tests; drugs, medications, biologicals,
				  anesthesia, and oxygen services; special duty nursing when medically necessary;
				  short-term physical therapy, radiation therapy, and inhalation therapy;
				  administration of whole blood and blood plasma; and short-term rehabilitation
				  services. Physician services include medically necessary health care services
				  performed, prescribed, or supervised by physicians within a hospital for
				  registered bed patients.
2.
				  Outpatient medical services. Medically necessary health care services
				  performed, prescribed or supervised by physicians for enrollees, which may be
				  provided in a nonhospital based health care facility, at a hospital, in a
				  physician's office, or in the enrollee's home, and shall include consultation
				  and referral services. Outpatient medical services shall also include
				  diagnostic services, treatment services, short-term physical therapy and
				  rehabilitation services the provision of which the health maintenance
				  organization determines can be expected to result in the significant
				  improvement of an enrollee's condition within a period of 90 days, laboratory
				  services, x-ray services, and outpatient surgery.
3. Diagnostic laboratory and diagnostic and
				  therapeutic radiologic services.
4.
				  Preventive health services shall be provided in accordance with the provisions
				  of § 38.2-3442 of the Code of Virginia.
5. In-area and out-of-area emergency
				  services, including medically necessary ambulance services, available on an
				  inpatient or an outpatient basis 24 hours per day, seven days per
				  week.
6. Mental health and
				  substance use disorder services shall be provided on parity with the medical
				  and surgical benefits contained in the plan in accordance with the Mental
				  Health Parity and Addiction Equity Act of 2008 (
				  P.L.
				  110-343 ).
7. Medically necessary dental services as a
				  result of accidental injury, regardless of the date of such injury. Contracts
				  may require that treatment be sought within 60 days of the accident for
				  injuries occurring on or after the effective date of coverage.